New Patient Intake — Dream Dental

01 · About you

The basics — we use this to start your chart.

First name *

Last name *

Date of birth *

Email

Phone *

Address

City

State

ZIP

02 · Insurance

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

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?

Allergies (medications, latex, etc.)

Medications you take regularly

04 · Dental history

When was your last dental visit?

Anything specific you’d like us to look at?

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.

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

Signature *

Type your full name to sign.