New Patient intake form - Triax Dental - Special Needs and General Dentistry in Nashville, TN

Version

Intake Form

Version 1.8

Please note that all fields with a (*) are required in order to successfully submit the intake form.

If you start the form but are not able to complete it you can save your progress and continue when it is convenient for you. To save simply click on the “Save and Continue Later” option at the bottom of the form and follow the prompts

Patient name:*

First Last

Date of birth:*

Patient's social security number*

Sex:*

Male
Female

Patient's Address:*

Street Address Address Line 2 City State ZIP Code

Phone number (1):*

Phone number (1) type:*

Mobile
Home
Work

Phone number (2):

Phone number (2) type:

Mobile
Home
Work

Ethnicity:*

As listed in https://grants.nih.gov/grants/guide/notice-files/NOT-OD-15-089.html

Height:*

Weight:*

Please enter a number from 30 to 400.

Reason for seeking treatment?*

Please upload patient's ID (Driver License, State ID, etc):

Drop files here or

Medical History

Conditions : check all that applies*

(if no conditions, check the first option)

Please provide details about items checked above*

Is the patient diabetic?*

Yes
No

If (yes), list HbA1C (%):

Do you have any disease, disorder, or complication not mentioned above?*

Yes
No

Please list any disease, disorder, or complication not mentioned above*

Have there been any changes in your general health in the last year?*

Yes
No

Please list the changes in your general health in the last year*

Medications

Do you take any medications?*

Yes
No

Please list medications you are currently taking*

Have you taken or are you currently taking any bisphosphonates (Fosamax, Zometa, Actonel, Boniva, Didronel) for Osteoporosis, Multiple Myeloma, or Cancer Therapy?*

Yes
No

Please list the name and when you went on the medication*

Have you ever required antibiotics prior to dental appointments?*

Yes
No

Please describe the need to take antibiotics prior to dental appointments*

Medical Allergies

Please check/list all medical allergies*

(if no known allergies check the first option)

Please list any other medication allergies*

Insurance Information (PPO, Medicaid, ECF, TennCare, CoverKids, etc)

*At this time, we are not in-network with any HMO or DHMO dental plans.

Does the patient have dental insurance or a Medicaid Program (like TN State Waiver, ECF, ICF, etc) that covers dental?

Yes
No

Please check all insurance types that apply to the patient*

Some patients have more than one insurance. Check all that apply.

ISP Date (MM/DD)*

Is the patient the policy holder for the Primary PPO Insurance plan?*

Yes
No

Policy holder name for the Primary PPO Insurance*

First Middle Last

Policy holder social security number for the Primary PPO Insurance*

Policy holder date of birth for the Primary PPO Insurance*

Please upload Primary Policy holder ID (Driver License, State ID, etc.)

Drop files here or

Insurance Provider (carrier) for the Primary PPO Insurance plan:*

Example: Delta Dental, UHC, MetLife, Aetna, BCBST, etc

Subscriber/Member ID for the Primary PPO Insurance plan:*

Group ID for the Primary PPO Insurance plan:

Please upload Front of Primary PPO Insurance card:

Please upload Back of Primary PPO Insurance card:

Is the patient the policy holder for the Secondary PPO Insurance plan?*

Yes
No

Policy holder name for the Secondary PPO Insurance:*

First Middle Last

Policy holder social security number for the Secondary PPO Insurance:*

Policy holder date of birth for the Secondary PPO Insurance:*

Please upload Secondary Policy holder ID (Driver License, State ID, etc.):

Insurance Provider (carrier) for the Secondary PPO Insurance plan:*

Example: Delta Dental, UHC, MetLife, Aetna, BCBST, etc

Subscriber/Member ID for the Secondary PPO Insurance plan:*

Group ID for the Secondary PPO Insurance plan:

Please upload Front of Secondary PPO Insurance card:

Please upload Back of Secondary PPO Insurance card:

Contact info

Responsible party for scheduling appointment*

Name	E-mail	Cell phone number	Home phone number

Does the patient have a Conservator or Legal Guardian?*

Yes
No

Conservator or Legal Guardian info*

Name	E-mail	Cell phone number	Home phone number

Pharmacy info*

Name	Phone number	Address	Fax number

Please note: name and phone number are required.

Primary Care Physician*

Name	Office phone number	Office fax number	E-mail

Please note: name and phone number are required.

ISC / CM*

Name	E-mail	Cell phone number	Office phone number

Support Coordinator*

Name	E-mail	Cell phone number	Office phone number

ICF*

Facility name	Billing contact	E-mail	Phone number

Clinical/other questions

Have you had any problems with dental treatment in the past?*

Yes
No

Please comment about past problems with dental treatment*

Will the patient require Oral or IV Sedation?*

Yes
No

Does the patient have any problems with sedation or general anesthesia in the past?*

Yes
No

Please comment about past problems with sedation or general anesthesia*

Has the patient ever been hospitalized or undergone any surgeries?*

Yes
No

Please describe hospitalizations and surgeries*

Does the patient use any assistive devices?

Wheelchair
Walker
Hoyer lift (please come to appointment with sling under patient)

Do you want to upload any x-rays, exams, etc?

Drop files here or

Referral info

How did you find out about us?*

Patient photo

Please add a photo to patient profile:

You can use your smartphone, tablet or upload a photo from your computer.

Acknowledgement

Name of the person filling out this form:*

First Last

Relationship to patient:*

Self
Family
Caregiver

E-mail for the person filling out this form:*

Do you wish to receive a copy of this form?*

Yes
No

Please sign to confirm: withholding any information about the patient’s health could seriously jeopardize his/her safety. Therefore, I have reviewed the above medical health history carefully and have answered all questions truthfully and to the best of my knowledge.*

By clicking the "Submit" button, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature.