Follow the steps to successfully complete the form online.

1. Press the ‘Get Form’ button to access the intake form and open it in your preferred online editor.
2. Begin by entering the patient’s name and the date in the designated fields. Ensure accurate spelling and the correct date format.
3. Indicate the patient’s gender and marital status using the radio buttons provided. Input the email address for communication purposes.
4. Fill in the Social Security Number (SSN), birthday, and contact numbers. If applicable, specify your preferred method of contact from email, telephone, or text message.
5. Complete the address section with the patient's current residence details.
6. Provide information about the parent or guardian. Enter their name, SSN, birthdate, phone number, address, employer, and occupation.
7. Move on to the primary dental insurance information. Fill in the insurance plan name and the policy holder's details. Ensure to include the policy and group numbers.
8. If applicable, also complete the secondary insurance information similarly to the primary insurance section.
9. Enter the name of the emergency contact along with the person who referred you to the practice, if any.
10. For the dental history section, provide details about the previous dentist, last cleaning, and last X-rays. Be honest about any dental complications experienced in the past.
11. Specify the frequency of brushing and flossing. Indicate whether an electric or manual toothbrush is being used.
12. List any dental concerns by checking the applicable boxes. If your concern is not listed, provide specifics in the space provided.
13. After filling out all the sections, review the form for accuracy. Make any necessary corrections and ensure all required fields are completed.
14. Finally, save your changes, download the form if needed, or print it for submission.

Complete your documents online today for a seamless dental experience.