Patient intake

New Patient Intake

A standard intake form for new patients — demographics, insurance, medical history, dental history, and consent. Edit anything you like.

Takes about 5–10 minutes · Your responses are private

01 · About you

The basics — we use this to start your chart.

First name *

Last name *

Date of birth *

Phone *

Address

City

State

ZIP

02 · Insurance

Skip if you’re paying out of pocket — we’ll work it out at the visit.

Snap a photo of your insurance card

Front and back — we’ll pull the details from it so you don’t have to type them.

Insurance provider

Policy / member number

Group number

03 · Medical history

Anything we should know about before treating you.

Do you currently have any of the following?

DiabetesHigh blood pressureHeart conditionPregnantAnxiety or panicNone of the above

Do you have any allergies?

Medications you take regularly

04 · Dental history

When was your last dental visit?

Anything specific you’d like us to look at?

Have a photo of what’s bothering you?

Optional — a quick photo helps us prepare for your visit.

How do you generally feel about dental visits?

Totally comfortableA little nervousAnxious — go slow with meI dread it

No judgment — this helps us pace your visit.

05 · Consent

Standard acknowledgment so we can treat you.

Notice of Privacy Practices

We protect your health information under HIPAA and only share it to coordinate your care, handle billing, or where the law requires. You can ask for a full copy of our Notice of Privacy Practices at any time.

I acknowledge receipt of the practice’s Notice of Privacy Practices (HIPAA). *

Signature *

Type your full name to sign.

Your responses go directly to Mammoth Spring Dental and are kept confidential.