Patient Intake Form - Dresher Family Dental

Please complete the following if you have dental insurance

Name of insured/subscriber(Required)

Date of Birth(Required)

Place of Employment(Required)

Insurance Company(Required)

Policy/Group #(Required)

Certificate/ID #(Required)

Upload Photo of Insurance Card

Drop files here or

Max. file size: 50 MB, Max. files: 100.

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.

When was your last medical checkup?(Required)

Please Specify(Required)

Please list and provide dosages. If there is insufficient room, please provide the name and address of your pharmacy.

--select--(Required)

Please list below with approximate dates(Required)

Please specify(Required)

If yes, please specify:(Required)

What is your expected delivery date?(Required)

Do you have any specific dental concerns? Please list:

When was your last dental appointment?(Required)

Is there anything about the appearance of your teeth that you would like to change?

REQUEST APPOINTMENT

Patient Registration Form

Patient Information

Contact Information

In case of emergency, please notify:

Contact Options

Medical History

Dental History

Hours

Monday:	8 am – 4 pm
Tuesday:	8 am – 6 pm
Wednesday:	9 am – 6 pm
Thursday:	8 am – 4 pm
Friday:	8 am – 2 pm