New Patient Intake Form
Fill this out ahead of your visit to save time at check-in. Bring it with you along with your ID and insurance card.
Patient Information
Full legal name
Date of birth
Phone number
Email address
Home address
Emergency Contact
Name
Phone
Relationship to patient
Dental Insurance (if applicable)
Insurance carrier
Member / group ID
Policyholder name (if not patient)
Reason for Today's Visit
Medical History
☐ Currently taking blood thinners or heart medication
☐ Diabetes
☐ Pregnant
☐ Allergic to penicillin or other antibiotics
☐ Allergic to latex or local anesthetic
☐ Prior heart valve or joint replacement (may require antibiotic pre-med)
Other conditions or current medications
Consent
I authorize Emergency Dental to provide diagnostic and emergency treatment as needed and to bill my insurance carrier directly. I understand that I am responsible for any amount not covered by insurance.