Patient Intake Form | Batavia Family Dental

Please complete the following if you have dental insurance

Name of insured/subscriber*

Place of Employment*

Upload Photo of Insurance Card

Drop files here or

Max. file size: 50 MB, Max. files: 100.

Medical History

The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by Doctor/Patient confidentiality. The Dentist will review the questions and explain any that you do not understand. Please complete the entire form.

When was your last medical checkup?*

Please list and provide dosages. If there is insufficient room, please provide the name and address of your pharmacy.

Please list below with approximate dates*

If yes, please specify:*

What is your expected delivery date?*

Do you have any specific dental concerns? Please list:

When was your last dental appointment?*

Is there anything about the appearance of your teeth that you would like to change?

Patient Registration Form

Patient Information

Contact Information

In case of emergency, please notify:

Contact Options

Medical History

Dental History

Monday:	8:30 am to 7 pm
Tuesday:	8:30 am to 6 pm
Wednesday:	8:30 am to 5 pm
Thursday:	8:30 am to 5 pm

Patient Registration Form

Patient Information

Contact Information

In case of emergency, please notify:

Contact Options

Medical History

Dental History

Request Appointment Form