Brightleaf Dental
Healthy smiles for the whole family
New Patient
Intake Form
52 Magnolia Lane · Savannah, GA 31401
(912) 555-0163
Welcome to the practice! We're so glad you chose us. Please fill out this form before your first visit so we can give you a comfortable, personalized appointment. Questions? Just ask our front-desk team.
For office use · Chart # ________
1 · About YouPlease print clearly
2 · Contact & Insurance
3 · Your SmileTell us about your teeth
Do any of these apply? Check all that fit
Tooth pain or sensitivity Bleeding gums Grinding or clenching Bad breath Loose teeth Jaw clicking / TMJ Interested in whitening Dental anxiety
4 · Health HistoryImportant for safe dental care
Heart condition
High blood pressure
Diabetes
Blood thinners
Bleeding disorder
Asthma
Latex allergy
Pregnant / nursing
Joint replacement
Epilepsy / seizures
Thyroid disorder
Other (note below)
Current medication
Dose
How often
For
5 · Consent

I certify that the information above is accurate to the best of my knowledge, and I will inform the practice of any changes to my health. I acknowledge that I have received Brightleaf Dental's Notice of Privacy Practices describing how my health information may be used and disclosed under HIPAA, and I consent to a dental examination, cleaning, and necessary treatment.

I understand I am responsible for any charges not covered by my dental insurance, and I authorize the practice to file claims on my behalf.

I have read, understand, and agree to the statements above.
Patient signature
Printed name
Date
If the patient is a minor: parent / guardian signature ___________________________ Printed name __________________ Date ________
Brightleaf Dental · Confidential patient record Form BL-200 · Rev. 2026