Online Intake Forms - The Hills Family Dentistry

Personal Information

Your basic contact and demographic information

First Name *

Last Name *

Preferred Name

Date of Birth *

Gender

Marital Status

How did you find our office? *

Email Address *

Phone Number *

Street Address *

City *

State *

ZIP Code *

Emergency Contact Name

Emergency Contact Phone

Insurance & Pharmacy Information

Your dental insurance details and preferred pharmacy for prescriptions

Insurance Information

Do you have dental insurance? *

Insurance Type

Primary Insurance Company

Group Number

Member/Subscriber ID

Relationship to Policyholder *

Secondary Insurance (if applicable)

Employer (for insurance verification)

Preferred Pharmacy

Pharmacy Name

Pharmacy Phone

Pharmacy Address

City

State

ZIP Code

I don't have a preferred pharmacy

Consent & Authorization

Please review and acknowledge the following agreements

Electronic Signature

Patient Signature *

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By typing your name above, you acknowledge that this serves as your legal electronic signature and that all information provided is accurate and complete.

Date *

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Personal Information

Medical History

Cardiovascular

Blood Disorders

Respiratory

Endocrine

Cancer/Oncology

Mental Health

Autoimmune

Other Conditions

Insurance & Pharmacy Information

Insurance Information

Policyholder Information

Preferred Pharmacy

Consent & Authorization

Electronic Signature

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San Elijo Hills Dentist

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