Dental New Patient Intake Form
Personal Information
First Name
Last Name
Date of Birth
Gender
Female
Male
Other
Prefer not to say
Address
City
State
Zip Code
Phone Number
Email Address
Insurance Information
Insurance Provider
Policy Number
Group Number
Subscriber Name
Subscriber Date of Birth
Medical History
Are you currently under a physician's care?
Yes
No
List any medical conditions
List current medications
List allergies
Do you smoke or use tobacco?
Yes
No
Dental History
Reason for today's visit
When was your last dental visit?
Do your gums bleed while brushing or flossing?
Yes
No
Are your teeth sensitive to hot or cold?
Yes
No
Other dental concerns
Emergency Contact
Name
Relationship
Phone Number
Signature
Date