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Tonganoxie Dental

504 E. 4th St Tonganoxie KS 66086

Tonganoxie Dental

504 E. 4th St Tonganoxie KS 66086

HOME
ABOUT US
- Meet Our Team
SERVICES
Invisalign
Botox/Dermal Fillers
GALLERY
PATIENT FORMS
CAREERS
FAQS
CONTACT US

CLIENT INTAKE FORM

Client Intake Form

Date

Email

Free Text

Client Information

Client Name

I prefer to Be Called

Phone:

Gender

Female

Male

Birthday

SS#

Driver's License #

Home Phone

Cell Phone

Work Phone

May we leave a voice message on these devices?

Yes

No

Address

City

State

ZIP Code

Whom may we thank for referring you?

Employer

How long there?

Free Text

Responsible Party Information Other Than Self?

Name

Relationship to Patient

Phone #

Employer

SS #

Billing Address

Free Text

Spouse Information

Civil Status

Married

Single

Divorced

Widowed

Separated

Spouse / Partner Name

Birthdate

Phone #

Free Text

Primary Insurance Information

Dental Coverage

Yes

No

Medical Coverage

Yes

No

Orthodontic

Yes

No

Insurance CO Address

Insured's Name

Insured's SS #

Insured's Birthdate

Relationship to Patient

Insured's Employer

Free Text

Secondary Insurance

Insurance CO Name

Phone #

Group Plan #

Insurance CO Address

Insured's Name

Insured's SS #

Insured's Birthdate

Relation to Patient

Insured's Employer

Employer's Address

Why are you seeking care?

Have you experienced problems associated with any previous dental work?

Yes

No

Do you now or have ever experienced pain/ discomfort in your jaw?

Yes

No

Do you use any dental hygiene aids?

Yes

No

Is yes, what?

How long has it been since you've seen a dentist?

How long has it been since you've had your teeth cleaned?

Do you smoke or use tabacco in any form?

Yes

No

Do your gums bleed?

Yes

No

Have you ever had periodontal disease?

Yes

No

Are any of your teeth loose?

Yes

No

Are your teeth sensitive?

Yes

No

Sensitive to

Heat

Cold

Sweets

Are you happy with your smile?

Yes

No

If not, what would you change?

Previous Dentist

Why did you leave?

Your current physical health is

Good

Fair

Poor

Are you currently under the care of a physician?

Yes

No

If yes, please explain

Physician's Name

Address

Phone

Date of Last Visit

Are you taking or scheduled to begin taking either of these medications?

Yes

No

New Field

Alendronate (Fosamax)

Residronate (Actonel) for osteoporosis

Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous bisphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from pagets disease, multiple Myeloma, or cancer?

Yes

No

Date treatment began

Doctor

Free Text

Do you have any of the following?

Abnormal Bleeding

Yes

No

Headaches

Yes

No

Shingles

Yes

No

Heart Attack

Yes

No

High Blood Pressure

Yes

No

Diabetes

Yes

No

Lupus

Yes

No

Steroid Therapy

Yes

No

Hemophilia

Yes

No

Radiation Treatment

Yes

No

Colitis

Yes

No

Liver Disease

Yes

No

Alcohol Abuse

Yes

No

Low Blood Pressure

Yes

No

Anemia

Yes

No

Heart Murmur

Yes

No

Sinus Problems

Yes

No

Mitral Valve Prolapse

Yes

No

Hepatitis

Yes

No

Stroke

Yes

No

Arthritis

Yes

No

Asthma

Yes

No

Blood Transfusion

Yes

No

Cancer

Yes

No

Chemotherapy

Yes

No

Chicken Pox

Yes

No

Emphysema

Yes

No

Epilepsy

Yes

No

HIV/AIDS

Yes

No

Tuberculosis

Yes

No

Please list any allergies (medications, metals, latex, anesthetics, etc.)

Please list all current medications, supplements, herbal remedies, vitamins, over the counter medications

Medication

Dose

Frequency

What taking for

Free Text

Botox

Have you ever had Botox or other brands, dermal filler, or other cosmetic procedures?

Yes

No

If so, what did you have?

Date of last treatment

If not, are you interested in learning about them?

Yes

No

Thank you for contacting us.
We will get back to you as soon as possible.

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HOME
ABOUT US
SERVICES
GALLERY
CAREERS
CONTACT US

Mon - Fri: 7:00 am - 6:00 pm
Sat - Sun: Closed

504 E. 4th St Tonganoxie KS 66086

tonganoxiedental@gmail.com

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