Please complete all sections accurately. This information is kept confidential under HIPAA regulations.

1. Patient Demographics

2. Emergency Contact

3. Insurance Information

Primary Dental Insurance

Secondary Dental Insurance (if applicable)

4. Medical & Dental History

4.1 Medical History

Have you ever been diagnosed with or had treatment for any of the following? (Check all that apply)

4.2 Dental History

Have you experienced any of the following?

5. Teledentistry Technology Requirements

6. Consent for Electronic Communications

7. COVID-19 & Health Screening

Within the past 14 days, have you experienced any of the following? (Check all that apply)

8. Privacy Notice & HIPAA Acknowledgment

Your Smile Partners PLLC protects your health information under HIPAA. Our Notice of Privacy Practices describes how we may use and disclose your protected health information. A copy is available upon request or at arrival to your first appointment.

9. Signature & Authorization

I certify that the information provided is complete and accurate to the best of my knowledge. I understand that withholding information may be detrimental to my health. I authorize the dental team of Your Smile Partners PLLC to perform teledentistry services, diagnostic procedures, and treatments as deemed necessary.

If signed by a representative

Thank you for choosing Your Smile Partners PLLC. We look forward to providing you with exceptional virtual dental care.