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New Patient Intake Form

HomeNew Patient Intake Form

Patient First Name *

Patient Last Name *

Patient Date of Birth *

Patient Street Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

Care Home Name of the Patient *

Patient Phone Number *

Power of Attorney (POA) / Decision maker First Name *

Power of Attorney (POA) / Decision maker Last Name *

POA Mailing Address *

Apartment, suite, etc

City *

State/Province *

ZIP / Postal Code *

Country *

POA Phone Number *

POA Cell Number *

POA Email *

Preferred way of communication *

EmailPhoneText

Will you be present for the appointment? *This helps us know how to schedule appointments. We always look forward to meeting the family/ friends.

Does the Patient have Dental Insurance that you would like us to assist with submission for? *If yes, please provide us with information so we can assist with the electronic claim submission.

Is there a specific day that works best for the Patient and or POA? *

MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Referral Information - Check boxes for each service required

Amanda Bolle Registered Dental HygienistAmanda Bolle DenturistAmanda Bolle both services needed (Dental Hygiene and Denture)

Referring Phone Number

Referring Facility/ Location Phone Number

Referring Dentist

Referring Facility/ Location

Treatment Information - Select one or more DENTURE treatments to be discussed or in need of:

Emergency CareOral Cancer ScreeningNew Denture FabricationComplete DenturePartial DentureImmediate DentureImplant SupportedDenture RelineRepair (Broken Denture)Repair (Teeth/ clip additions)Name label in denture

Treatment Information - Select one or more DENTAL HYGIENE treatments to be discussed or in need of:

New Client Exam/ Consultation - Dental Assessment and treatment planningEmergency CareOral Cancer ScreeningDenture ExamDental Cleaning (Scaling, polish, fluoride)Desensitizing applicationSilver Diamine Fluoride (SDF) applicationTemporary Filling Placement (IST)Name label in denture

Additional Comments

Contact Us

(Mailing Address) 30 Conniston Ave, Ottawa ON K2H 5H8
613-406-7808
info@ottawamobiledental.com

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