New Patient Form

If you are a first time patient and would like to save time, you can download these 2 forms clicking here, you will need pkunzip to extract the 2 files.  Click here to download winzip.

If you have any questions please e-mail us at info@lentinesmile.com.

New Patient Intake Data
Date: 8/19/2008
First Name:
Last Name:
Middle Initial:
Sex MF
Social Security Number: - -
Daytime Phone: - -
Evening Phone: - -
Best Time to Call:
Email Address:
Address
Apt.:
City:
State:
Zip:
Occupation:
Employer:
Address:
Address (cont.):
City:
State:
Zip:
FAMILY INFORMATION:
Name of Spouse or Parent:
Closest Relative:
Relationship:
Phone: - -
FINANCIAL INFORMATION:
who is responsible for payment?
First Name:
Last Name:
Middle Initial:
Social Security Number: - -
Address:
Address (cont.):
City:
State:
Zip:
Daytime Phone: - -
Evening Phone: - -
Insurance Company or "Carrier":
Group Plan Name:
Address:
Address (cont.):
City:
State:
Zip:
Phone: - -
OTHER INFORMATION
If you are completing this form for another person, what is your relationship to that person?
If you were referred to us by someone else, please tell us whom to thank:
If you were not referred to us by someone else, how did you hear about us?
 
Special Note About Insurance

If you wish us to help you be reimbursed by insurance policies which you have purchased, we’ll be glad to assist you in whatever way we can. While we’re happy to offer you choices for various methods of payment, we cannot, of course, argue with your bank if there’s no money in your checking account; and, obviously, we cannot charge your Master Card/Visa if your credit has been suspended. Likewise, we should not be expected to chase your insurance company or employer for money they owe you (even though you owe it to us). Please try to understand that any arrangements you have made with someone else to pay for dental services is strictly between you and them. Although we want to help you in every way we can, prompt payment for healthcare services rendered to you and your family by this office always remains your responsibility.
HOBBIES AND INTERESTS
Please help us get to know you a little better by telling us about your leisure interests. Check off as many items as are applicable.

Aerobics Boats Camping Flying Music
Animals Books Gardening Politics Skating
Antiques Bowling Golf Hiking Theater Art
Classes Cooking Swimming Team Sports Auctions
Collecting Dining Jogging Tennis Automobiles
Computers Horses Sailing Wood work Bicycling
Crafts Knitting Skiing Travel Bingo
Dancing Fishing Museums Sewing
GENERAL HEALTH
General Health ExcellentGoodFairPoor
Name of Physician:
Address:
Address (cont.):
City:
State:
Zip:
Phone: - -
Have you been treated by a physician during the past year? YesNo
If yes, why?
Do you have any alergies? YesNo
If yes, please describe:
Are you presently taking any medicines or drugs? YesNo
If yes, please list, and indicate purpose:
Have you ever had any excessive bleeding requiring special treatment? YesNo
Check off any of the following illnesses which you have had:
Kidney Disease Heart Problems Radiation Treatments
Heart Murmur Jaundice Fainting
Tumors Anemia Epilepsy
Mitral Valve Prolapse Rheumatic Fever Thyroid Problems
Hip/Knee or Prosthetic High Blood Pressure Tuberculosis
Arthritis Measles Asthma
Diabetes AIDS/HIV Positive Nervous Problems
Venereal Disease
(Women) Are you pregnant at the present time? YesNo
DENTAL INFORMATION
Name of former dentist:
When was your last dental treatment performed?
What is your present dental problem?
Have you experienced any unfavorable reaction to previous dental treatments? YesNo
If yes, please explain:
STATEMENT OF ACCURACY
To the best of my knowledge, these answers are true, current, and accurate as of today's date.
Entering your name below serves as your signature and indicates your acceptance of this statement of accuracy. If the patient is under eighteen (18) years of age, this form must be signed by a parent or legal guardian.
Signature: Date: