Patient Intake Form
Your trusted partner in navigating dental and medical care. We help you understand insurance, treatment plans, and advocate for your needs.
Start Your Intake Form
Patient Information Collection
Personal Details
We collect your name, birth date, and contact information to provide personalized service.
Insurance Information
Both dental and medical insurance details help us advocate effectively on your behalf.
Provider Details
Information about your dental practice ensures coordinated communication.
Medical and Dental History
Current Dental Concerns
Share any ongoing dental issues or conditions requiring attention.
Chronic Medical Conditions
Inform us about health conditions that might impact your dental care.
Treatment History
Previous treatments help us understand your complete health picture.
Our Advocacy Services
Appointment Scheduling
We coordinate with dental offices to find convenient appointment times.
Treatment Plan Reviews
Get help understanding complex dental treatment recommendations.
Insurance Navigation
We explain benefits and assist with claims and billing issues.
Verbal Advocacy
We speak directly with providers and insurance companies on your behalf.
Consent to Services
Voluntary Participation
Your participation is entirely voluntary. You can decline or stop services anytime.
Information Disclosure
You authorize us to access and share your health information as needed for advocacy.
Decision Responsibility
Final decisions about your dental care remain your responsibility.
Confidentiality
All information is treated with strict confidentiality under HIPAA regulations.
Liability Understanding
Not Medical Advice
Our guidance is informational only, not medical advice.
Personal Responsibility
Consult qualified professionals for diagnosis and treatment.
No Guaranteed Results
We cannot guarantee specific outcomes from our services.
Release of Liability
You agree to release us from claims related to your participation.
Membership Benefits

Advocacy Services
We communicate with providers and insurance companies on your behalf.

Communication Consent
Receive updates via your preferred contact method.

Monthly Subscription (optional)
$35/month for basic services with additional options available.

Member Discounts
Active members receive discounted rates on additional services.
Complete Your Membership
How do I submit my completed form?
You can email your completed form through this link electronically or Admin@PatientAdvocateProgram.org or mail it to address 1420 E Roseville Parkway Suite 140-PMV 163, Roseville CA 95661
How do I cancel my membership?
Send a written cancellation request via email to admin@patientadvocateprogram.org.
What if I have more questions?
Contact us at (707) ASK-NDAP or email Admin@PatientAdvocateProgram.org with any questions.