New Patient intake form (Nashville Office)

Please note that this intake form is for the Nashville location only.

If you are looking to become a patient at the Chattanooga office, please use this link below:
https://mdvdds.com/chattanooga/

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Version
V2.1.1 : Legal Guardian fields (change)
Intake Form (for the Nashville Office)
Version 2.1.1
Please note that all fields with a (*) are required in order to successfully submit the intake form.

If you start the form but are not able to complete it you can save your progress and continue when it is convenient for you. To save simply click on the “Save and Continue Later” option at the bottom of the form and follow the prompts
Patient name:(* required)
First Last
Date of birth:(* required)
Sex:(* required)
- Male
- Female
Patient's Address:(* required)
Street Address Address Line 2 City State ZIP Code
Phone number (1):(* required)
Phone number (1) type:(* required)
- Mobile
- Home
- Work
Phone number (2):
Phone number (2) type:
- Mobile
- Home
- Work
Ethnicity:(* required)
As listed in https://grants.nih.gov/grants/guide/notice-files/NOT-OD-15-089.html
Height:(* required)
Weight:(* required)
Please enter a number from 30 to 400.
Patient preferred language?(* required)
Other preferred language(* required)
Reason for seeking treatment?(* required)
Please upload patient's ID (Driver License, State ID, etc):
Drop files here or

Max. file size: 256 MB.
Medical History
Conditions : check all that applies(* required)
- No significant medical findings
- Cardiovascular Disease - Heart Attack
- Angina
- Atherosclerosis
- Stroke
- History of infective endocarditis
- Artificial heart valve
- Heart defects
- High blood pressure
- Hepatitis
- Liver disease (If yes, list type)
- Kidney disorders
- GERD or heartburn
- Stomach ulcers
- HIV or AIDS (If yes, please list meds)
- Autoimmune disorders
- Arthritis
- Osteoporosis
- Emphysema
- Bronchitis
- COPD
- Tuberculosis
- Asthma
- Seizures (If yes, list type and frequency)
- Low blood pressure
- Syncope
- Intellectual or developmental disability
- Mental health disorders
- Anemia
- Sickle cell anemia
- Bleeding disorders (If yes, list type)
- Thyroid disorders
- Sleep apnea
- Eating disorders
- Cyclic vomiting syndrome
- Cancer (If yes, list type and treatment)
- Pregnant
- Nursing
- Alcohol abuse
- Drug abuse
- Tobacco use (please list type, amount per day and years of use)
(if no conditions, check the first option)
Please provide details about items checked above(* required)
Is the patient diabetic?(* required)
- Yes
- No
If (yes), list HbA1C (%):
Do you have any disease, disorder, or complication not mentioned above?(* required)
- Yes
- No
Please list any disease, disorder, or complication not mentioned above(* required)
Have there been any changes in your general health in the last year?(* required)
- Yes
- No
Please list the changes in your general health in the last year(* required)
Medications
Do you take any medications?(* required)
- Yes
- No
Please list medications you are currently taking(* required)
Have you taken or are you currently taking any bisphosphonates (Fosamax, Zometa, Actonel, Boniva, Didronel) for Osteoporosis, Multiple Myeloma, or Cancer Therapy?(* required)
- Yes
- No
Please list the name and when you went on the medication(* required)
Have you ever required antibiotics prior to dental appointments?(* required)
- Yes
- No
Please describe the need to take antibiotics prior to dental appointments(* required)
Medical Allergies
Please check/list all medical allergies(* required)
- Check here if no known drug allergies
- Local or topical anesthetic
- Antibiotics
- Aspirin
- Codeine
- Opiates
- Benzodiazepines
- Other (please list)
(if no known allergies check the first option)
Describe allergic reaction(s)(* required)
Please list any other medication allergies(* required)
Insurance Information (PPO, Medicaid, ECF, TennCare, CoverKids, etc)
*At this time, we are not in-network with any HMO or DHMO dental plans.
Please check all insurance types that apply to the patient(* required)
- PPO Dental Insurance Primary (Delta, BCBS, UHC or Cigna)
- PPO Dental Insurance Secondary (Delta, BCBS, UHC or Cigna)
- TennCare: Adult Dental Plan
- TennCare: DIDD 1915c Waiver (SD, SW and CAC)
- TennCare: Children Medicaid/Coverkids
- TennCare: ECF Choices
- TennCare: Intermediate Care Facility (ICF)
- Patient doesn't have insurance
Some patients have more than one insurance. Check all that apply.
Patient's social security number(* required)
ISP Date (MM/DD)(* required)
Is the patient the policy holder for the Primary PPO Insurance plan?(* required)
- Yes
- No
Policy holder name for the Primary PPO Insurance(* required)
First Middle Last
Policy holder social security number for the Primary PPO Insurance(* required)
Policy holder date of birth for the Primary PPO Insurance(* required)
Please upload Primary Policy holder ID (Driver License, State ID, etc.)
Drop files here or

Max. file size: 256 MB.
Insurance Provider (carrier) for the Primary PPO Insurance plan:(* required)

Example: Delta Dental, UHC, MetLife, Aetna, BCBST, etc
Subscriber/Member ID for the Primary PPO Insurance plan:(* required)

Sometimes your Subscriber/Member ID is your Social Security Number (for Delta Dental Insurance, for example)
Group ID for the Primary PPO Insurance plan:
Please upload Front of Primary PPO Insurance card:
Max. file size: 256 MB.
Please upload Back of Primary PPO Insurance card:
Max. file size: 256 MB.
Is the patient the policy holder for the Secondary PPO Insurance plan?(* required)
- Yes
- No
Policy holder name for the Secondary PPO Insurance:(* required)
First Middle Last
Policy holder social security number for the Secondary PPO Insurance:(* required)
Policy holder date of birth for the Secondary PPO Insurance:(* required)
Please upload Secondary Policy holder ID (Driver License, State ID, etc.):
Max. file size: 256 MB.
Insurance Provider (carrier) for the Secondary PPO Insurance plan:(* required)

Example: Delta Dental, UHC, MetLife, Aetna, BCBST, etc
Subscriber/Member ID for the Secondary PPO Insurance plan:(* required)

Sometimes your Subscriber/Member ID is your Social Security Number (for Delta Dental Insurance, for example)
Group ID for the Secondary PPO Insurance plan:
Please upload Front of Secondary PPO Insurance card:
Max. file size: 256 MB.
Please upload Back of Secondary PPO Insurance card:
Max. file size: 256 MB.
Does the patient have a Rep Payee(* required)
- Yes
- No (patient is the Rep Payee)
Info: Rep Payee is the person responsible for billing and payments not covered by insurances
Name of Rep-payee (or Responsible Party) for payments/billing:(* required)

Write 'self' if the patient is responsible to pay for non-covered services.
Email of Rep-payee (or Responsible Party):(* required)

* required field
Mailing address for Rep-payee (or Responsible Party):(* required)
Street Address Address Line 2 City State ZIP Code

* required field
Contact info
Responsible party for scheduling appointment(* required)
Name E-mail Cell phone number Home phone number
Pharmacy info(* required)
Name Phone number Address Fax number
Please note: name and phone number are required.
Primary Care Physician(* required)
Name Office phone number Office fax number E-mail
Please note: name and phone number are required.
ISC / CM(* required)
Name Agency
Support Coordinator(* required)
Name Insurance (BCBST, UHC or Amerigroup) E-mail
ICF(* required)
Facility name Billing contact E-mail Phone number
Does the patient have a Conservator or Legal Guardian?(* required)
- Yes
- No
Conservator or Legal Guardian info
Conservator or Legal Guardian name(* required)
Conservator or Legal Guardian email(* required)
Conservator or Legal Guardian cell phone number
Conservator or Legal Guardian home phone number
Clinical/other questions
Have you had any problems with dental treatment in the past?(* required)
- Yes
- No
Please comment about past problems with dental treatment(* required)
Will the patient require Oral or IV Sedation?(* required)
- Yes
- No
What kind of sedation has the patient had in the past for dental treatment?(* required)
Does the patient have any problems with sedation or general anesthesia in the past?(* required)
- Yes
- No
Please comment about past problems with sedation or general anesthesia(* required)
Has the patient ever been hospitalized or undergone any surgeries?(* required)
- Yes
- No
Please describe hospitalizations and surgeries(* required)
Does the patient use any mobility assistive devices or have a mobility risk?(* required)
- Yes
- No
Patient will be transported by wheelchair at our office
Does the patient use a Hoyer Lift for transfers?(* required)
- Yes (please come to appointment with SLING under patient)
- No
Do you want to upload any x-rays, exams, etc?
Drop files here or

Max. file size: 256 MB.
Referral info
How did you find out about us?(* required)
- Google
- Yelp!
- Facebook
- Friends or Family
- Insurance Company
Patient photo
Please add a photo to patient profile:
Max. file size: 256 MB.
You can use your smartphone, tablet or upload a photo from your computer.
Acknowledgement
Name of the person filling out this form:(* required)
First Last
Relationship to patient:(* required)
- Self
- Family
- Caregiver
E-mail for the person filling out this form:(* required)
Do you wish to receive a copy of this form?(* required)
- Yes
- No
Please sign to confirm: withholding any information about the patient’s health could seriously jeopardize his/her safety. Therefore, I have reviewed the above medical health history carefully and have answered all questions truthfully and to the best of my knowledge.(* required)
By clicking the "Submit" button, you are signing this form electronically. You agree your electronic signature is the legal equivalent of your manual/handwritten signature.

Save and Continue Later

New Patient intake form (Nashville Office)

Intake Form (for the Nashville Office)

Medical History

Medications

Medical Allergies

Insurance Information (PPO, Medicaid, ECF, TennCare, CoverKids, etc)

Contact info

Conservator or Legal Guardian info

Clinical/other questions

Referral info

Patient photo

Acknowledgement