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New Patient
Intake Form
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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
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4 · Health HistoryImportant for safe dental care
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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 {{ practice_name_consent }}'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 ________
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