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[HEALTH] Dentist New Patient Intake Form
[HEALTH] Dentist New Patient Intake Form
In order to provide you with the highest standard of dental care, your cooperation in completing this questionnaire is essential for [ENTER ORGANIZATION NAME]. All information is strictly confidential and will remain with the office. [ENTER ORGANIZATION NAME, ADDRESS] Phone:
(123) 456-6789
Email:
YourName@YourEmail.com
Website:
YourWebsite.com
Page 1 of 3 - Registration
33%
Welcome to our Practice
Our Location
REGISTRATION INFORMATION
Please complete the following
The patient is an:
*
Adult
Child
Adult under Guardianship
Name of Guardian (if applicable)
First
Last
Patient's name
*
First
Last
Address
*
No Preference
Work
Home
Delivery
Address Type
Street Address
Address Line 2
Apartment
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
Reason for today's visit?
*
Examination
Emergency
Other
Home phone
*
-
###
-
###
####
Cell phone
-
###
-
###
####
Work phone
-
###
-
###
####
Driver's license
Scan Barcode
S.I.N.
Scan Barcode
Date of birth (DD/MM/YY)
*
Scan Barcode
Age
*
Scan Barcode
Sex
*
Male
Female
Email Address
Scan Barcode
Confirm Email
*
How did you learn about our office?
*
Newspaper
Internet
Flyer
Yellow Pages
Building sign
Referred by:
Are other family members patients at our office?
*
Yes
No
DENTAL INSURANCE
(if applicable)
Name of person responsible for your account:
Self
Other
Do you have Primary Dental Insurance?
Yes
No
Do you have Secondary Dental Insurance?
Yes
No
Name of PRIMARY Insured:
First
Last
Date of birth (DD/MM/YY)
Scan Barcode
PRIMARY Insurance Company
Scan Barcode
Group Policy number
Scan Barcode
Certificate or I.D. number
Scan Barcode
Name of SECONDARY Insured: (if applicable)
First
Last
Date of birth (DD/MM/YY)
Scan Barcode
SECONDARY Insurance Company
Scan Barcode
Group Policy number
Scan Barcode
Certificate or I.D. number
Scan Barcode
IMPORTANT CONTACTS
Required information
In case of an emergency, contact
*
Scan Barcode
Relationship
*
Scan Barcode
Emergency contact telephone
*
-
###
-
###
####
Family Physician
Scan Barcode
Family Physician address
No Preference
Work
Home
Delivery
Address Type
Street Address
Address Line 2
Apartment
City
State / Province / Region
Postal / Zip Code
Afghanistan
Albania
Algeria
Andorra
Antigua and Barbuda
Argentina
Armenia
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Central African Republic
Chad
Chile
China
Colombia
Comoros
Congo
Costa Rica
Côte d'Ivoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
East Timor
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Fiji
Finland
France
Gabon
Gambia
Georgia
Germany
Ghana
Greece
Grenada
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Mauritania
Mauritius
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
New Zealand
Nicaragua
Niger
Nigeria
Norway
Oman
Pakistan
Palau
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Poland
Portugal
Puerto Rico
Qatar
Romania
Russia
Rwanda
Saint Kitts and Nevis
Saint Lucia
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia and Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
Spain
Sri Lanka
Sudan
Suriname
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Togo
Tonga
Trinidad and Tobago
Tunisia
Turkey
Turkmenistan
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
Yemen
Zambia
Zimbabwe
Country
Family Physician phone
-
###
-
###
####
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