New Patient intake form HiddenVersionV1.91 : Rep-payee fields were added (add), 2021-05-25Intake FormVersion 1.91Please 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:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Sex:* Male Female Patient's Address:* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Phone number (1):*Phone number (1) type:* Mobile Home Work Phone number (2):Phone number (2) type: Mobile Home Work Ethnicity:*American Indian or Alaska NativeAsianBlack or African AmericanCaucasian (white)HispanicNative Hawaiian or Other Pacific IslanderOtherAs listed in https://grants.nih.gov/grants/guide/notice-files/NOT-OD-15-089.htmlHeight:*4 ft. 0 in.4 ft. 1 in.4 ft. 2 in.4 ft. 3 in.4 ft. 4 in.4 ft. 5 in.4 ft. 6 in.4 ft. 7 in.4 ft. 8 in.4 ft. 9 in.4 ft. 10 in.4 ft. 11 in.4 ft. 12 in.5 ft. 0 in.5 ft. 1 in.5 ft. 2 in.5 ft. 3 in.5 ft. 4 in.5 ft. 5 in.5 ft. 6 in.5 ft. 7 in.5 ft. 8 in.5 ft. 9 in.5 ft. 10 in.5 ft. 11 in.5 ft. 12 in.6 ft. 0 in.6 ft. 1 in.6 ft. 2 in.6 ft. 3 in.6 ft. 4 in.6 ft. 5 in.6 ft. 6 in.6 ft. 7 in.6 ft. 8 in.6 ft. 9 in.6 ft. 10 in.6 ft. 11 in.6 ft. 12 in.7 ft. 0 in.7 ft. 1 in.7 ft. 2 in.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 Select files Max. file size: 50 MB. Medical HistoryConditions : check all that applies* No significant medical findings Cardiovascular Disease - Heart Attack, Angina, Atherosclerosis, Stroke History of infective endocarditis, artificial heart valves, heart defects High blood pressure Hepatitis or liver disease (If yes, list type) Kidney disorders GERD or heartburn Stomach ulcers HIV or AIDS (If yes, please list meds) Autoimmune disorders Arthritis Osteoporosis Respiratory problems - Emphysema, Bronchitis, COPD, Tuberculosis Asthma Seizures (If yes, list type and frequency) Low blood pressure or syncope Intellectual or developmental disability Mental health disorders Anemia or sickle cell anemia Bleeding disorders (If yes, list type) Thyroid disorders Sleep apnea Eating disorders Cyclic vomiting syndrome Cancer (If yes, list type and treatment) Pregnant or nursing Alcohol abuse Drug abuse Tobacco use (please list type, amount per day and years of use) (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* MedicationsDo 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 AllergiesPlease check/list all medical allergies* Check here if no known drug allergies Local or topical anesthetic Penicillin/other antibiotics Aspirin Codeine Opiates Benzodiazepines Other (please list) (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.HiddenDoes 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* PPO Primary (Delta, UHC, MetLife, etc) PPO Secondary (Delta, UHC, MetLife, etc) Medicaid Waiver (SD, SW, CAC) TennCare / CoverKids ECF ICF Patient doesn't have insurance Some patients have more than one insurance. Check all that apply.Patient's social security number* ISP Date (MM/DD)*Month123456789101112Day12345678910111213141516171819202122232425262728293031YYYY2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Is 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*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please upload Primary Policy holder ID (Driver License, State ID, etc.) Drop files here or Select files Max. file size: 50 MB. Insurance Provider (carrier) for the Primary PPO Insurance plan:* Example: Delta Dental, UHC, MetLife, Aetna, BCBST, etcSubscriber/Member ID for the Primary PPO Insurance plan:* Sometimes your Subscriber/Member ID is your Social Security Number (for Delta Dental Insurance, for example)Group ID for the Primary PPO Insurance plan: Please upload Front of Primary PPO Insurance card:Max. file size: 50 MB.Please upload Back of Primary PPO Insurance card:Max. file size: 50 MB.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:*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year2022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Please upload Secondary Policy holder ID (Driver License, State ID, etc.):Max. file size: 50 MB.Insurance Provider (carrier) for the Secondary PPO Insurance plan:* Example: Delta Dental, UHC, MetLife, Aetna, BCBST, etcSubscriber/Member ID for the Secondary PPO Insurance plan:* Sometimes your Subscriber/Member ID is your Social Security Number (for Delta Dental Insurance, for example)Group ID for the Secondary PPO Insurance plan: Please upload Front of Secondary PPO Insurance card:Max. file size: 50 MB.Please upload Back of Secondary PPO Insurance card:Max. file size: 50 MB.Name of Rep-payee (or Responsible Party) for payments/billing:* Write 'self' if the patient is responsible to pay for non-covered services.Email of Rep-payee (or Responsible Party):* * required fieldMailing address for Rep-payee (or Responsible Party):* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code * required field Contact infoResponsible party for scheduling appointment*NameE-mailCell phone numberHome phone numberDoes the patient have a Conservator or Legal Guardian?* Yes No Conservator or Legal Guardian info*NameE-mailCell phone numberHome phone number Pharmacy info*NamePhone numberAddressFax numberPlease note: name and phone number are required.Primary Care Physician*NameOffice phone numberOffice fax numberE-mailPlease note: name and phone number are required.ISC / CM*NameE-mailCell phone numberOffice phone numberSupport Coordinator*NameE-mailCell phone numberOffice phone numberICF*Facility nameBilling contactE-mailPhone number Clinical/other questionsHave 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 Select files Max. file size: 50 MB. Referral infoHow did you find out about us?* Google Yelp! Facebook Friends or Family Insurance Company Patient photoPlease add a photo to patient profile:Max. file size: 50 MB.You can use your smartphone, tablet or upload a photo from your computer. AcknowledgementName 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.
