Dental Clinic Intake Form
Dental Clinic Intake Form
Please complete this form to help us understand your dental needs and provide you with the best care.
Name
Date of Birth
Address
Phone number
Medical History
Current Medical Conditions
Allergies
Medications
Previous Dental Treatments
Insurance Information
Insurance Provider
Policy Number
Emergency Contact
Name
Phone number
Consent and Acknowledgments
By signing below, you acknowledge that you understand the treatment consent, privacy policy, and financial responsibilities associated with your dental care. Your signature confirms your agreement to these terms.
Name:
Date:
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