Patient Intake Form
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1Today’s Date: _____________________
Patient Intake Form
Name:
Date of Birth:
Care Card #:
Address:
City:
Postal Code:_
No Fixed Address:
Home Phone:
Cell Phone:
Cell Phone Texting: Yes
No
Email:
Contact Person's Name:
Contact Person's Phone:
Email:
In pain? Yes
No
On Waitlist: Yes
No
Last Dental Visit:
Who referred you?:
Main Concern:
Appointment Date/Time:
Financial Assessment Completed:
Yes
No
Approved:
Yes
No
Insurance Plan:
MSD
H Kids
Disability
NIHB
DVA
Social
Premium
PWD
First
Veteran
Services
Assistance
Nations
Affairs
Insurance Carrier:
________
Group # ________
ID #________
Dep #________
Insurance Limitations:
______________
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Parent category: Business