New Patient Form

Patient Name

Date of Birth

Address

Phone Number

Email Address

Do you have dental insurance?

Yes (If yes, please fill out the section below) No

Primary Insurer

Certificate / ID Number

Group / Policy number

Are you a dependant? Yes / No

Name of insurer

Insurer date of birth

Relationship

Secondary Insurer

Certificate / ID Number

Group / Policy number

Are you a dependant? Yes / No

Name of insurer

Insurer date of birth

Relationship

How did you hear about our clinic?*

MEDICAL HISTORY - Do you have a family physician?

Yes No

Name

Phone

Do you have a dentist?

Yes No

Name

Phone

Have you ever had any head, facial, jaw or neck trauma?

Yes No

Additional condition details

Do you smoke?*

Yes No

Are you allergic to the following?

Latex Metal Acrylic Other

Please specify allergy

Have you ever had or are going through radiation or chemotherapy?

Yes No

When did you last go through radiation or chemotherapy?

Do you have hearing or memory issues where you may need extra assistance?

Yes No

If you have a serious illness that is not listed, please list

Is there anything else the denturists should know about your health?

Consent

I, the undersigned, certify that all the medical and dental information provided is true to the best of my knowledge, and I have not knowingly omitted any information. I consent to my Dentist, previous Denturist or Physician being contacted if necessary, as further dental/medical information may be required for my dental care. I, the undersigned, hereby consent to the performing of the preventative dental procedures. I, the undersigned, am aware that the whole amount of treatment is due to be paid by me and understand any direct billing to my insurance plan that comes back unpaid is to be paid promptly by me. l authorize release to my benefits plan administrator information contained in claims submitted electronically. I also authorize the communication of information related to the coverage of services described to the named denturist. This authorization shall continue in effect until the undersigned revokes the same.

SMS Notifications

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Name

Date

Subject