Healthcare General Patient Intake Form

Healthcare General Patient Intake Form

Intake form for the Medical Industry Create a HIPAA Compliant Healthcare General Patient Intake Form today. Form Preview
  • General Patient Information

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  • Insurance - Primary

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  • Insurance - Secondary

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  • Nearest relative not living with you:

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  • Medical History

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  •   Yes No
    Abnormal Bleeding
    Alcohol Abuse
    Angina Pectoris
    Artificial Heart Valve
    Blood Transfusion
    Congenital Heart Defect
    Difficulty Breathing
    Drug Abuse
    Facial Surgery
    Fainting Spells
    Fever Blisters
    Frequent Headaches
    HIV + AIDS
    Heart Attack
    Heart Murmur
    Heart Surgery
    Hepatitis A
    Hepatitis B
    Hepatitis C
    High Blood Pressure
    Joint Replacement
    Kidney Problems
    Liver Disease
    Low Blood Pressure
    Mitral Valve Prolapse
    Pace Maker
    Psychiatric Care
    Radiation Therapy
    Rheumatic Fever
    Sexually Transmitted Disease
    Sickle Cell Disease
    Sinus Problems
    Thyroid Problems
  •   Yes No
    Are you taking birth control pills?
    Are you nursing?
    Are you pregnant?
  • Assignment and Release

  • I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Dr. Corey L. Plaster, DDS all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurances. I hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions. I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.

  • Responsible Party Signature: ___________________________________ Date:______________

    (The signature above will be physically signed when at dental office.)

  • Dental History

  •   Yes No
    Do you require antibiotics before dental treatment?
    Are you currently in pain?
    Do you now or have you had any pain/discomfort in your jaw joint?
    Are you aware of clenching or grinding your teeth?
    Does it hurt when you chew or open wide to take a bite?
    Do you have any jaw symptoms or headaches upon waking up in the morning?
    Do you have pain in the face, cheeks, jaw, joints, throat or temples?
    Do you like your smile?
    Is there anything you would like to change about your smile?
    Are you happy with the color of your teeth?
    Have you ever had gum disease?
    Do your gums bleed?
    Have you ever had a deep cleaning or scaling and root planing?
  • How many times do you:

  •   Yes No
    Are your teeth sensitive to heat, cold or anything else?
    Do you take fluoride supplements?
    Have you ever had a serious/difficult problem with any previous dental work?
    Have you ever had any unfavorable dental experiences?
    Are you apprehensive about dental treatment?
    Do you gag easily?
  • Should be Empty: