(770) 478-1001
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New Patient Intake

Please complete the form below before your visit. It takes about 5–10 minutes. Fields marked are required.

Who is this form for?
Patient Information
Person Responsible for the Account
Emergency Contact
Dental Insurance
Upload Documents (optional)

You may upload photos of your driver's license and insurance card now for a faster check-in. Uploading here is optional — but please note a valid ID and your insurance card are required in the office at the time of your appointment.

Dental History
Do you experience any of the following? (check all that apply)
Any of these gum problems? (check all that apply)
Do you currently have any of these? (check all that apply)
Medical History
Allergies (check all that apply)
Have you ever had any of the following? (check all that apply)
Consent for Communications (optional)

These preferences are optional and will not affect your ability to receive care or complete this form. Let us know how you'd prefer we reach you about appointments, reminders, and billing. You can change or withdraw your consent at any time by contacting our office.

Standard message and data rates may apply for text messages. Highmark Dental will never sell or share your contact information with third parties for marketing. You may revoke consent at any time by replying STOP to a text, or by calling (770) 478-1001.

Acknowledgement & Signature

This consent covers diagnostic examination and x-rays only. Any individual treatment procedure will require additional, separate consent.

HIPAA Privacy Notice

The information you submit is protected under the Health Insurance Portability and Accountability Act (HIPAA). Your personal and health information will be used only to schedule and coordinate your dental care. We will never sell your information or share it without your written authorization, except as required by law or for treatment, payment, and healthcare operations.

By submitting this form, you acknowledge receipt of our Notice of Privacy Practices. To exercise your HIPAA rights or report a privacy concern, call us at (770) 478-1001 or email info@highmarkcares.com.

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