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Bonita Medical Center

Santa Fe
1700 Hospital Drive
Santa Fe, NM 87505

(505) 988-2121

Mon–Thu: 8:00 AM–5:00 PM
Fri: 8:00 AM–12:00 PM

Contact Us

Patient Intake Form

Account Information

Primary Dental Insurance Information

Secondary Dental Insurance Information

Medical History

It is important to provide accurate information to ensure a safe and successful surgery/procedure.

Are you in good health?

Has there been any change in your general health in the past year?

Are you now under a physician’s care for a particular problem?

Have you ever had any serious illness, surgery or hospitalization?

Do you have or have you ever had:

Rheumatic Fever or Rheumatic Disease?

Congenital Heart Disease?

Kidney Disease?


Thyroid Disease?


Stomach Ulcers or Colitis?



Implants placed anywhere in your body (Heart Valve, Pacemaker, Hip, Knee)?

Sinus or Nasal problems?

Any disease, drug or transplant operation that has depressed your immune system?

Cardiovascular Disease: Heart Attack, Heart Trouble, Heart Murmur, Angina, Stroke?

Lung Disease: Asthma, Emphysema, COPD, Chronic Cough, Bronchitis, Pneumonia?

Seizures, Convulsions, Epilepsy, Fainting, Dizziness

Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion, Bruise Easily?

Liver Disease: Jaundice, Hepatitis

Radiation from X-ray, Cancer Treatment Radiation

Clicking or Popping of Jaw Joint, Pain Near Ear, Difficulty Opening Mouth, Grind or Clench Teeth?

Are you using any of the following?


Anticoagulants (Blood Thinners)?

Aspirin, Ibuprofen, Acetometaphin or other over-the-counter pain relievers?

High Blood Pressure medications?

Steroids (Cortisone, Prednisone, etc.)?


Insulin or Oral Anti-Diabetic drugs?

Digitalis, Inderal, Nitroglycerin or other heart drug?

Are you taking or have you ever taken Bisphosphonates for osteoporosis, multiple myeloma?

Are you currently taking any antidepressant or anxiety medication?

Do you smoke or chew Tobacco?

Is there any personal or family history of Alcohol, Chemical Dependency?

Have you had any problems associated with any previous dental treatment?

Have you ever had a bone density scan?

Have you had an HIV Blood test?

Have you ever had Hepatitis A, B, or C?

Are you allergic to or have you have an adverse reaction to:

Local Anesthesia (Novacain, etc.)?

Penicillin or other antibiotics?

Aspirin or Ibuprofen?

Codeine or other pain killers?

Latex or Rubber products?

Metal of any kind?

Food products?

Other allergies or reactions?

Women Only

Are you pregnant, or is there any chance you might be pregnant?

Are you are using Oral Contraceptives?

Are you nursing?

Financial Responsibility

Patients are responsible for full payment at the time of service. We accept cash, checks and all major credit cards. Minors accompanied or unaccompanied are responsible for full payment at the time of service. Non emergency treatment will be denied unless charges have been pre-authorized to an approved credit plan or a major credit card. If your insurance plan is accepted at Bonita Medical Center, you must pay at least 40% of total charges at time of service (some procedures require 50% payment), if your insurance has not paid the full balance within 45 days you will need to pay the balance within fifteen business days. A 1.5% finance charged will be added to all past due accounts. Insurance coverage is a contract between you and your provider. We file insurance claims as a courtesy to our patients. Bonita Medical Center will not be involved in disputes of any kind with your insurance company. However we will be happy to supply factual information as needed. Bonita Medical Center is a non-participating Medicare/Medicaid provider. There is a $100.00 charge for missed appointments and cancellations with less that 24 hour notice. I understand that it is my responsibility to fill out this form completely and correctly. I have provided accurate information and assume financial responsibility for all services rendered.