English Rows Dental Group Patient Intake Form

Patient Intake Form

At English Rows Dental Group, we value your time. That’s why patients can now complete their intake form online—fast, private, and hassle-free.

If you would prefer to download your forms and bring them in with you please do.

Downloadable Forms

"*" indicates required fields

Step 1 of 8 - Personal Information

Personal Information

Please take a moment to fill out your personal information in this section of the form.

Patient's Name*

First Last

Date of Birth*

Parent/Guardian Name

First Last

Sex*

Male

Female

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Cell Phone

Business Phone

Enter Email Confirm Email

Smile Reminder

Please check here so we will place you in our Smile Reminder system which will provide you with email and text message reminders of upcoming appointments.

Smile Reminder Notification

Guarantor Name*

First Last

Drivers License Number

Other Family Members

Patient Last 4 SSN*

We will collect the entire SSN when you arrive for your visit

Spouse/Parent Last 4 SSN

We will collect the entire SSN when you arrive for your visit

Primary Insurance Coverage

Please provide us with your primary insurance information.

Do you have Dental Insurance?*

Yes

Do you have a Secondary Dental Insurance Policy?*

Yes

Employee Name*

First Last

Employee Date of Birth*

Employer Name*

Years Employed

Primary Insurance Company*

Primary Insurance Company Phone

Primary Insurance Company Address

Street Address Address Line 2 City State ZIP Code

Primary Insurance Policy Number

Employee Last 4 SSN*

Union Local or Group

Secondary Insurance Coverage

Please provide us with your secondary insurance information.

Employee Name

First Last

Date of Birth

Employer Name

Years Employed

Secondary Insurance Company

Secondary Insurance Phone

Secondary Insurance Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Secondary Insurance Policy Number

Employee Last 4 SSN

Union Local or Group

Dental History

Purpose of Initial Visit*

Are there any concerns you would like addressed?

Is there anything that you would change with your teeth?

Would you be interested in an esthetic evaluation with before and after simulations?

Yes

Previous dental experience

When was your last professional dental cleaning?

When was your last dental visit?

What was done?

Dentist Name

(If known)

First Last

Dentist's Address

Street Address Address Line 2 City State ZIP Code

Have you made regular dental visits in the past?*

Yes

How often?

Were x-rays taken?

Yes

Have you had any complications with dental treatment in the past?

Yes

Please explain:

Certification and Acknowledgement

By submitting this online form you are acknowledging all of your answers to be true and accurate. You are also acknowledging that you are in agreement with the English Rows Dental Group Privacy Policy and HIPAA guidelines. You are also providing your agreement to the following statements: I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care. I consent to the dentist's use and disclosure of my records (or my child's records) to carry out treatment, to obtain payment, and for those activities and health care operations that are related to treatment or payment. I consent to the disclosure of my records (or my child's records) to the following persons who are involved in my care (or my child's care) or payment for that care. My consent to disclosure of records shall be effective until I revoke it in writing. I authorize payment directly to the dentist or dental group or insurance benefits otherwise payable to me. I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services, and that I am financially responsible for payment in full on all accounts. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, by my dental care payor. Please type your name and indicate today's date as your acknowledgement below.

Name

First Last

Date

I can smile with complete confidence! I can’t now imagine ever being concerned about appearing in photos. It’s just been a new lease of life. Thank you.

Laura H
Patient

Ready To Smile?

Book an appointment

Patient Intake Form

Personal Information

Primary Insurance Coverage

Secondary Insurance Coverage

Dental History

Previous dental experience

Dental Habits & Appearance

Appearance

Missing Teeth

Other Dental Questions

Teeth Grinding

Jaw Issues

Other Miscellanous Dental Questions

Medical History

Certification and Acknowledgement

I can smile with complete confidence! I can’t now imagine ever being concerned about appearing in photos. It’s just been a new lease of life. Thank you.

Ready To Smile?