Patient Intake Form

Email Address

Today's Date

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

First Name

Last Name

Middle Initial

Home Phone

Cell Phone

Work Phone

Preferred Method of Contact

Phone

Text

Mailing Address

City

State

Zip

Height

Weight

Date of Birth

Sex

Occupation

Emergency Contact

How did you hear about us?

If you are completing this form for another person, what is your relationship to that person?

Your Name

Relationship

Home Phone

Cell Phone

Dental Information

Are your teeth sensitive to cold, hot, sweets or pressure?

Yes

Does food or floss catch between your teeth?

Yes

Is your mouth dry?

Yes

Have you had any periodontal (gum) treatments?

Yes

Have you ever had orthodontic (braces) treatment?

Yes

Have you ever had any problems associated with previous dental treatment?

Yes

Is your home water supply fluoridated?

Yes

Do you drink bottled or filtered water?

Yes

If yes, how often?

Daily

Weekly

Occasionally

Do you have earaches or neck pains?

Yes

Do you have any clicking, popping, or discomfort in the jaw?

Yes

Do you brux or grind your teeth?

Yes

Do you have sores or ulcers in your mouth?

Yes

Do you wear dentures or partials?

Yes

Do you participate in active recreational activities?

Yes

Have you ever had a serious injury to your head or mouth?

Yes

Are you currently experiencing dental pain or discomfort?

Yes

Chief Complaint

Date of your last dental exam

What was done at that time?

Date of last cleaning

Medical Information

Are you currently under the care of a physician?

Yes

Physician Name

Phone Number

Address / City / State / Zip

Are you in good health?

Yes

Has there been any change in your general health within the past year?

Yes

If yes, what condition is being treated?

Date of last physical exam

Do you have a history of chemical dependency?

Yes

Are you in recovery?

Yes

If yes, how long have you been in recovery?

Do you use controlled substances (drugs)?

Yes

Do you use tobacco (smoking, snuff, chew, bidis)?

Yes

If so, how interested are you in stopping?

Very

Somewhat

Not Interested

Do you drink alcoholic beverages?

Yes

If yes, how much alcohol did you drink in the last 24 hours?

Have you had a serious illness, operation or been hospitalized in the past 5 years?

Yes

If yes, what was the illness or problem?

Do you take any blood thinners?

Yes

Do you take aspirin on a regular basis?

Yes

Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax), risedronate (Actonel), ibandronate (Boniva), or any other bisphosphonates?

Yes

Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Yes

If yes, please list all medications, including vitamins, natural or herbal preparations and/or diet supplements

Women Only Are you:

Pregnant?

Yes

Number of weeks

Taking birth control pills or hormonal replacements?

Yes

Nursing?

Yes

Have you ever had an orthopedic total joint (hip, knee, elbow, finger) replacement?

Yes

If yes, date

If yes, have you had any complications?

Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.

Local anesthetics

Yes

Aspirin

Yes

Penicillin or other antibiotics

Yes

Barbiturates, sedatives, or sleeping pills

Yes

Sulfa drugs

Yes

Codeine or other narcotics

Yes

Metals

Yes

Latex (rubber)

Yes

Iodine

Yes

Hay fever / seasonal

Yes

Animals

Yes

Food / Other

Yes

If yes, please specify

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

Heart murmur

Yes

Mitral valve prolapse

Yes

Artificial heart valves

Yes

Rheumatic fever

Yes

Cardiovascular disease

Yes

Angina

Yes

Arteriosclerosis

Yes

Congestive heart failure

Yes

Coronary artery disease

Yes

Damaged heart valves

Yes

Heart attack

Yes

Low blood pressure

Yes

High blood pressure

Yes

Congenital heart defects

Yes

Pacemaker

Yes

Rheumatic heart disease

Yes

Abnormal bleeding

Yes

Anemia

Yes

Blood transfusion

Yes

If yes, date

Hemophilia

Yes

AIDS or HIV infection

Yes

Arthritis

Yes

Autoimmune disease

Yes

Rheumatoid arthritis

Yes

Systematic lupus erythematosus

Yes

Asthma

Yes

Bronchitis

Yes

Emphysema

Yes

Sinus trouble

Yes

Tuberculosis

Yes

Cancer / Chemotherapy / Radiation treatment

Yes

Chest pain upon exertion

Yes

Chronic pain

Yes

Diabetes type I or type II

Yes

Eating disorder

Yes

Malnutrition

Yes

Gastrointestinal disease

Yes

GE Reflux / persistent heartburn

Yes

Ulcers

Yes

Thyroid problems

Yes

Stroke

Yes

Glaucoma

Yes

Hepatitis, jaundice, or liver disease

Yes

Epilepsy

Yes

Fainting spells or seizures

Yes

Neurological disorders

Yes

If yes, please specify

Gag Reflex Sensitivity

Yes

Sleep disorder

Yes

Mental health disorders

Yes

If yes, please specify

Recurrent infections

Yes

If yes, type of infection

Kidney problems

Yes

Night sweats

Yes

Osteoporosis

Yes

Persistent swollen glands in neck

Yes

Severe headaches / migraines

Yes

Severe / rapid weight loss

Yes

STDs / STIs

Yes

Excessive urination

Yes

ADD

Yes

ADHD

Yes

Sensory Processing Disorder

Yes

Oral Sensory Sensitivity

Yes

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Yes

Do you have any disease, condition, or problem not listed above that you think we should know about?

Yes

If yes, please explain

Pharmacy Information

Pharmacy Name

Pharmacy Phone

Pharmacy Address

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

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Patient Details Form

Spouse or Responsible Party Information

Who is the responsible party for this account?

the patient

the patients spouse

the person responsible for payment

The following is for the individual who has been check-boxed above:

Last Name

First Name

Middle Initial

Preferred Name

Social Security #

Date of Birth

Cell

Work

Ext

Best Time to Call

Address

City

State

Zip

Patient Employment Information

Employer Name

Occupation

Employer Address

Employer City

Employer State

Employer Zip

Employer Phone

Referral Information

Whom may we thank for referring you to our practice?

another patient, friend

another patient, relative

Dental Office

Newspaper

School

Mail Flyer

Other

If other, please specify

Name of person or office referring you to our practice

Insurance Information

Primary

Name of Insured

Is insured a patient?

Yes

Insured's Birth Date

ID #

Group #

Employer Address

Employer City

Employer State

Employer Zip

Insured's Employer Name

Patient's Relationship to Insured

Self

Spouse

Child

Other

If other, please specify

Insurance Plan Name and Address

Consent For Services

As a condition of your treatment by this office, payment for services is due at the time services are rendered unless financial arrangements have been made in advance. A fee may be charged for cancellations or rescheduling of appointments if less than 48 hours notice is given.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid at the time services are performed.

Patients who carry dental insurance understand that they are responsible for their portion of dental treatment and any remaining balance after insurance has paid. This office cannot render services on the assumption that our charges will be paid in full by your insurance company. Patient with dental insurance is to understand that fees given to them are an estimate only. I authorize the use of my signature on all insurance submissions and assign all insurance benefits directly to Main Street Dental, LLC.

I hereby authorize Main Street Dental, LLC, (collectively referred to as "Practice") to use and disclose the entire medical record, in accordance with our Notice of Privacy Practices (NOPP). I have reviewed the NOPP, been given an opportunity to ask questions about it, understand it and do hereby agree to its terms. A copy of this signed, dated Consent shall be effective as the original. I release, hold harmless and agree to indemnify Practice and its employees and agents for any and all liability (including but not limited to negligence) arising out of or occurring under this Consent. I specifically authorize Practice to use and disclose verbally, by mail, fax or unecrypted e-mail my information as stated in the NOPP.

I grant my permission to you or your assignee, to text, email, and / or telephone me at home or on my cell phone or at my work to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

Name of patient, parent, or guardian

Date

Relationship to Patient

Signature of patient, parent, or guardian

Date

Relationship to Patient

Signature of guarantor of payment/responsible party

Date

Relationship to Patient

Appointments and Cancellations

When we make your appointment, we are reserving a room for your particular needs. We ask that if you must change an appointment, please give us at least 48 hours notice. This courtesy makes it possible to give your reserved room to another patient who would like it.

There is a charge for not showing up for scheduled appointments. A $35.00 charge will be assessed for broken appointments and appointments cancelled without a 48-business hour advance notice. Repeated cancellations or missed appointments will result in loss of future appointment privileges.

We feel that our patient's time is valuable. When your appointment is made, a room is reserved, your records are prepared, and special instruments are readied for your visit. Except for emergency treatment for another patient, you can expect us to be prompt. We, of course, would appreciate the same courtesy from you.

I acknowledge that I have read the above statements, and agree to the office policies for appointments and cancellations.

Name of patient, parent, or guardian

Date

Relationship to Patient

Signature of of patient, parent, or guardian

Date

Relationship to Patient

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

Download Printable Version

Insurance Form

General Information

Patient Name

Date of Birth

Primary Dental Insurance

Policy Holder

Self

Other

Policy Holder Name (if not patient)

Relationship to Patient

Self

Spouse

Parent

Legal Guardian

Partner

Other

If other, please specify

Name of Employer

Work Phone

Address of Employer

City

State

Zip

Policy Holder Date of Birth

Insurance Company

Insurance Group #

Insurance Plan #

Effective Date

Assignment of Benefits & Authorization To Release Information

If I am entitled to benefits under any insurance policy or other health benefit plan (covering me or anyone legally responsible for me), in consideration of services provided to me, I assign, transfer and convey the benefits payable under such program, policy or plan for services rendered to me. I authorize payment of these benefits directly, with such benefits being applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge responsibility for and agree to pay charges not paid under this assignment, including any coinsurance amounts, deductibles, and any charges for service deemed to be non-covered, not pre-certified, or not pre-authorized by my insurance plan.

Initial

I give my consent for examination and treatment.

Initial

I authorize the release of information including the diagnosis, records, examination, treatment, radiology, and claims of information.

This information may be released to

Spouse

Family

Friend

Other Treating Physician(s)

Do Not Release my Medical Information

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

Download Printable Version

Records Release Form

To Whom It May Concern,

, authorize Main Street Dental to release any information regarding my dental health, in accordance with the attached Notice of Privacy Practices (NOPP). A copy of this signed, dated Consent shall be as effective as the original. I release and hold Main Street Dental, its employees and agents harmless from any and all liability (including but not limited to negligence) arising out of or occurring under this consent. I authorize disclosure of the entire dental record concerning patient,

, to the following:

Name

Relation

Phone Number

Name

Relation

Phone Number

Name

Relation

Phone Number

Name

Relation

Phone Number

Thank you,

Patient Signature

Date

Patient Name

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue