New patient intake · MyStar Dental

Patient info

Required so we can prepare the chart before your visit.

Patient's full name*

Patient's date of birth*

Email

Phone*

Address

Emergency contact name

Emergency contact phone

Insurance

We'll verify benefits before your visit so there are no billing surprises.

Carrier

Member / ID number

Group number

Subscriber name (if different)

Photo of insurance card (optional) 📷 Tap to upload front of card

Medical history

Check anything that applies — even if you think it doesn't affect your teeth, it might affect treatment.

Current medications

Allergies (medications, latex, anesthesia, anything)

Dental history

Helps us prioritize what matters at your first visit.

Concerns or pain you want addressed

Last dental visit (approximate)

HIPAA acknowledgment

Notice of Privacy Practices. The information you share is protected under HIPAA. We use it only for treatment, billing, and required reporting. We don't sell it, share it with marketers, or use it for any purpose outside your care. You can request a full copy of our privacy practices at any time.

I have read and acknowledge the privacy notice above.