New Patient formNew Patient Intake Form PATIENT INFORMATION * Patient Name . * Date of Birth* * Address * * Phone* * EmailDo you have dental insurance? Yes (If yes, please fill out the section below) No PRIMARY INSURER * Insurance company name Certificate / ID Number Group / Policy number Are you a dependant? Yes / No Name of insurer Insurer date of birth Relationship SECONDARY INSURER * Insurance company name 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 * PhoneDo you have a dentist? Yes No * Name * PhoneHave you ever had any head, facial, jaw or neck trauma? Yes NoDo any of the following conditions apply to you? Facial muscle tenderness Earaches Hearing issues Sore or tender gums Do you gasp or stop breathing in your sleep. Joint clicking, popping or locking TMJ (Jaw) pain Lumps or sores in your mouth now Do you snore a lot. Migraines or headaches Neck or shoulder pain Do you grind your teeth Burning sensation on your lips or tongue Additional condition detailsDo you smoke?* Yes NoAre you allergic to the following? Latex Metal Acrylic Other * Please specify allergyHave 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 NoDo you have any of the following serious illnesses? Heart condition Cold sores Tuberculosis Asthma High blood pressure Mouth cancer Diabetes Sinus trouble Hepatitus A/B/C HIV or AIDS Stroke Snoring Drug addiction Epilepsy or seizures Jaundice 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 Opt-In Yes, I agree to receive text messages from Precision Denture Care at the phone number listed above. Message frequency varies and may include appointment reminders, service or order information, promotional messages, etc.. Message and data rates may apply. Opt out at any time by replying ‘stop’ or ‘unsubscribe.’ No, I do not want to receive text messages from Precision Denture Care.See our Privacy policy for details on how we handle your information. We never share or sell your opt-in information. Name DateSubmit
