DENTAL NEW PATIENT INTAKE CHECKLIST: RECORDS & CONSENT

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--- PATIENT DEMOGRAPHICS & CONTACT INFORMATION ---
[ ] Patient First Name
[ ] Patient Last Name
[ ] Date of Birth (MM/DD/YYYY)
[ ] Patient Address
[ ] City
[ ] State
[ ] Zip Code
[ ] Phone Number
[ ] Email Address

--- MEDICAL & DENTAL HISTORY ---
[ ] Past Medical Conditions (e.g., Diabetes, Hypertension)
[ ] Current Medications (including dosage)
[ ] Blood Pressure (Systolic)
[ ] Blood Pressure (Diastolic)
[ ] Allergies (e.g., Penicillin, Latex) (No Known Allergies, Penicillin, Latex, Other)
[ ] Previous Dental Work & Concerns (including orthodontics)
[ ] Date of Last Dental Visit
[ ] Family History of Oral Health Issues (Cavities, Gum Disease, Oral Cancer, Temporomandibular Joint Disorder (TMJ), None)

--- CHIEF COMPLAINT & REASONS FOR VISIT ---
[ ] Describe Your Primary Concern
[ ] Select All Reasons for Visit (Routine Check-up, Cleaning, Toothache, Broken Tooth, Whitening, Orthodontics Consultation, Other (Please Specify))
[ ] If 'Other' selected, please specify:
[ ] Date of Last Dental Visit
[ ] Approximate Pain Level (1-10)

--- INSURANCE VERIFICATION & AUTHORIZATION ---
[ ] Patient Insurance Carrier
[ ] Policy Number
[ ] Group Number
[ ] Subscriber's Birth Year
[ ] Coverage Type (e.g., HMO, PPO) (HMO, PPO, DHMO, Indemnity)
[ ] Verification Date
[ ] Authorization Required? (Yes, No)
[ ] Authorization Number (if applicable)

--- CONSENT FORMS & DISCLOSURES ---
[ ] HIPAA Notice of Privacy Practices Acknowledgment (Received and Understood, Received, but Need Further Explanation)
[ ] Financial Policy Acknowledgment (Received and Understood, Received, but Need Further Explanation)
[ ] Detailed Explanation of Treatment Risks and Benefits (Dentist Notes)
[ ] Patient Signature
[ ] Date of Signature
[ ] Release of Information (if applicable) (Yes, Authorize Release, No, Do Not Authorize Release)
[ ] Supporting Documentation (e.g., insurance card copy)

--- REVIEW OF TREATMENT PLAN & ESTIMATES ---
[ ] Detailed Treatment Plan Discussion
[ ] Estimated Total Treatment Cost
[ ] Patient Portion Estimated Cost
[ ] Payment Options Discussed (Cash, Check, Credit Card, Financing (e.g., CareCredit))
[ ] Next Appointment Scheduled (if applicable)
[ ] Patient Understanding of Treatment Plan (Fully Understands, Understands Most, Requires Further Explanation)
[ ] Patient Signature Acknowledging Treatment Plan & Estimate

--- PATIENT ACKNOWLEDGMENT & SIGNATURE ---
[ ] Patient Printed Name
[ ] Patient Signature
[ ] Date of Acknowledgment
[ ] Patient Comments/Questions (Optional)
[ ] Do you understand the financial policy? (Yes, No)
[ ] Do you understand the HIPAA Notice? (Yes, No)

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