NEW PATIENT INTAKE FORM

    PATIENT INFORMATION

    Contact Information

    Birth Date:
    I authorize Cypress Dental to contact me via email and SMS.
    Preferred method of contact:

    Insurance Information

    - Primary Insurance

    Birth Date:

    - Secondary Insurance

    Birth Date:
    Many dental insurance plans allow us to submit claims electronically on your behalf. In order to do this, we require your authorization. I authorize the release of information contained in claims submitted electronically to my dental benefits provider. I authorize the communication of information related to dental coverage and benefits to my dental insurance provider. If allowed, I also assign my benefits payable from claims submitted electronically and authorize payment directly to this dental practice.

    Date:
    Signature of patient or parent/guardian of minor

    MEDICAL HISTORY

    1. Are you in good health?
    2. Are you presently receiving any treatment for any illness (i.e osteoporosis, cancer, upcoming surgeries, developmental delays)?
    3. Have you had any of the following: Prosthetic heart valve replacement, heart transplant, congenital heart disease, infective endocarditis.

    If yes, has your doctor instructed you to take pre-medications before dental treatment?
    4. Are you taking any medication or non-prescription drugs?
    5. Do you have allergies?

    6. Have you ever had a peculiar or adverse reaction to any medication or injections? (e.g. penicillin, aspirin, local anesthesia or dental freezing)
    Please check the box if you presently have or ever had any of the following:
    (If yes, due date *2)


    7.Is there any additional information related to your health that has not been addressed above (i.e. past or upcoming surgeries)?

    DENTAL HISTORY

    Last Dental Visit:
    Can we request your information from this office?
    How often do you visit the dentist?

    How often do you brush your teeth in a day?
    How often do you floss your teeth in a day?
    Please check the box if you presently have or ever had any of the following:
    Other issues:
    if yes, to:
    Have you ever had:
    Do you experience any of the following problems in your jaw:
    I would like to improve:


    Additional comments or concerns?
    Patient/Guardian signature

    WE WOULD LOVE TO GET TO KNOW YOU!

    These questions are optional but we appreciate you sharing.
    Why did you leave your last dentist:
    What kept you from completing your needed dentistry in the past?

    Is there anything you would like us to know?

    OUR MISSION

    Our office is committed to providing our patients with a dental experience that will promote a lifelong relationship built on trust, confidence, quality dentistry, and excellent patient care. Here at Cypress Dental we want to help change the way you feel about going to the dentist. Our specialized equipment, facility and staff are able to address all your dental needs in a relaxed and friendly manner.