During your first visit, our team will arrive with portable dental equipment designed specifically for safe, in-home care. We will review medical history, evaluate dental needs, and create a personalized treatment plan.

Appointments are focused on comfort, efficiency, and clear communication with patients and caregivers.

Patient intake form

Today's Date

Email Address

Full Name

I prefer to be called

Sex

Male Female Other/NA

Birth Date

Age

Home Address

Home Phone Number

Pager/Cell

Work Phone

Occupation/Job Title

When and Where Can We Reach You?

Whom can we thank for referring you?

Other family members seen by us

Previous/Present Dentist

Last Visit

Relationship to patient

I certify that I am legally authorized to provide this information on behalf of the patient.

Do you have a personal physician?

Yes No

Physician's Name

Work Phone Number

Date of Last Visit

Are you under the care of a physician?

Yes No

Please Explain...

Your current health is

Good Fair Poor

Are you currently taking any medication (prescription, over-the-counter or supplemental)?

Yes No

Please Include All

Do you smoke or use tobacco in any form?

Yes No

Have you ever taken Fosamax or any other bisphosphonate?

Yes No

Have you been told that you snore or hold your breath while sleeping or do you wake up gasping for air?

Yes No

For Women: Are you using birth control?

Yes No

For Women: Are you pregnant?

Yes No

Week Number?

For Women: Are you nursing?

Yes No

Have you ever had any of the following diseases or medical problems?

Anemia / Radiation Treatment

Yes No

Artificial Bones / Joints / Valves

Yes No

Arthritis

Yes No

Asthma

Yes No

Blood Transfusion

Yes No

Cancer / Chemotherapy

Yes No

Congenital Heart Defect

Yes No

Diabetes

Yes No

Difficulty Breathing

Yes No

Drug / Alcohol Abuse

Yes No

Emphysema / Glaucoma

Yes No

Epilepsy / Seizures / Fainting Spells

Yes No

Fever Blisters / Herpes

Yes No

Heart Attack / Stroke

Yes No

Heart Murmur

Yes No

Heart Surgery / Pacemaker

Yes No

Hemophilia / Abnormal Bleeding

Yes No

Hepatitis

Yes No

High or Low Blood Pressure

Yes No

HIV+ / AIDS

Yes No

Kidney Problems

Yes No

Mitral Valve Prolapse

Yes No

Psychiatric Treatment

Yes No

Rheumatic / Scarlet Fever

Yes No

Severe / Frequent Headaches

Yes No

Shingles

Yes No

Sickle Cell Traits / Disease

Yes No

Sinus Problems

Yes No

TB (Tuberculosis)

Yes No

Ulcers / Colitis

Yes No

Venereal Disease

Yes No

Hospitalized for Any Reason

Yes No

Please list any additional serious medical conditions you have ever had.

Are you allergic to any of the following?

Aspirin

Yes No

Codeine

Yes No

Dental Anesthetics

Yes No

Erythromycin

Yes No

Jewelry / Metals

Yes No

Latex

Yes No

Penicillin

Yes No

Tetracycline

Yes No

Other

Yes No

Please list any other drugs / materials you are allergic to.

Why have you come to the dentist today?

Do you require antibiotics before dental treatment?

Yes No

Are you currently in pain?

Yes No

Have you ever had a serious / difficult problem associated with any previous dental work?

Yes No

Do you now or have you ever experience pain / discomfort in your jaw joint? (TMJ / TMD)

Yes No

Your current dental health is

Good Fair Poor

Do you like your smile?

Yes No

Do your gums ever bleed?

Yes No

Have you ever had periodontal disease?

Yes No

How many times per week do you floss?

How many times per day do you brush?

Type of toothbrush bristles?

Soft Medium Hard

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

Digital signature field (typed name acceptable)

Date field

I confirm that the information provided is accurate to the best of my knowledge.

** Payment is due in full at time of treatment unless prior arrangements have been approved.

** Our office is HIPAA Compliant and committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC and the ADA.

** Thank you for filling out this form completely. It will enable us to help you more effectively. If you have any questions at any time, please ask us. We are happy to help.

First Visit

Patient intake form

Upload Documents

dentisthousecalls@gmail.com

First Visit

Patient intake form​

Upload Documents

Patient intake form