Your Smile Partners PLLC — Teledentistry New Patient Intake Form Teledentistry New Patient Intake Form Your Smile Partners PLLC 99 Wall St, New York, NY 10005 Email: talk@yoursmilepartners.com Print Form Save PDF to Device Submit & Upload Clear All Fields Please complete all sections accurately. This information is kept confidential under HIPAA regulations. 1. Patient Demographics Full Name Preferred Name/Nickname Date of Birth Gender Male Female Non-binary Prefer not to say Address City State ZIP Home Phone Cell Phone Email Address Preferred Method of Contact Phone SMS Email 2. Emergency Contact Name Relationship Phone Alternate Phone 3. Insurance Information Primary Dental Insurance Insurance Company Policy/ID Number Group Number Subscriber Name Subscriber Date of Birth Subscriber Employer Secondary Dental Insurance (if applicable) Insurance Company Policy/ID Number Group Number I authorize release of dental information to my insurance carrier and assign benefits directly to Your Smile Partners PLLC. Signature (Insurance Authorization) Clear Date 4. Medical & Dental History 4.1 Medical History Have you ever been diagnosed with or had treatment for any of the following? (Check all that apply) Heart disease/attack High blood pressure Stroke Diabetes Thyroid disorder Cancer Hepatitis HIV/AIDS Respiratory disease Kidney disease Liver disease Autoimmune disorder Psychiatric care Joint replacement Bleeding disorder Sleep apnea If Cancer, type If Joint replacement, date Other conditions List any hospitalizations or surgeries (with dates) Current medications (include dosage) Allergies (medications, latex, foods, environmental) 4.2 Dental History Reason for today’s visit Date of last dental exam and cleaning Have you experienced any of the following? Tooth pain Sensitivity to hot/cold Bleeding gums Loose teeth Jaw pain/locking Bruxism (teeth grinding) Difficulty chewing Sores or lesions in mouth Bad breath Dry mouth Previous orthodontic treatment Yes No Previous oral surgery Yes No 5. Teledentistry Technology Requirements Device you will use Smartphone Tablet Laptop/Desktop Operating system iOS Android Windows macOS Other Webcam Built-in External Internet connection Wi-Fi Cellular Ethernet Preferred video platform Zoom Doxy.me Microsoft Teams Other I confirm I have the required hardware and internet access for a successful teledentistry appointment. 6. Consent for Electronic Communications I consent to receive appointment reminders, educational materials, and clinical correspondence via my provided phone number and email. I understand message/data rates may apply. I may revoke this consent at any time by contacting talk@yoursmilepartners.com. 7. COVID-19 & Health Screening Within the past 14 days, have you experienced any of the following? (Check all that apply) Fever or chills Cough Shortness of breath Loss of taste/smell Sore throat Muscle aches Headache Gastrointestinal symptoms Tested positive for COVID-19 in the past 30 days? Yes No Vaccinated for COVID-19? Yes No Vaccine dates (if applicable) 8. Privacy Notice & HIPAA Acknowledgment Your Smile Partners PLLC protects your health information under HIPAA. Our Notice of Privacy Practices describes how we may use and disclose your protected health information. A copy is available upon request or at arrival to your first appointment. I acknowledge receipt of the Privacy Notice & HIPAA information. 9. Signature & Authorization I certify that the information provided is complete and accurate to the best of my knowledge. I understand that withholding information may be detrimental to my health. I authorize the dental team of Your Smile Partners PLLC to perform teledentistry services, diagnostic procedures, and treatments as deemed necessary. I agree to the above authorization. Patient Signature Clear Date If signed by a representative Representative Name Relationship to Patient Representative Signature Clear Date Thank you for choosing Your Smile Partners PLLC. We look forward to providing you with exceptional virtual dental care. Ready
