Patient Intake Form

Last Name

First Name

Middle Initial

Birthdate

Age

Marital Status

Social Security Number

Address

City

State

Zip Code

Home Phone

Cell Phone

Referred by

Reason For Visit?

Account Information

Person Responsible for Account

Relationship to Patient

Social Security

Date of Birth

Address

City

State

Zip Code

Home Phone

Cell Phone

Occupation

Employer

Primary Dental Insurance Information

Insurance Company

Phone Number

Address

City

State

Zip Code

Name of Insured

Date of Birth

Social Security Number

Relationship to Patient

Sex

Employer

Secondary Dental Insurance Information

Insurance Company

Phone Number

Address

City

State

Zip

Name of Insured

Date of Birth

Social Security Number

Relationship to Patient

Sex

Employer

Medical History

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

Are you in good health?

Yes

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

Yes

Date of your last physical exam?

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

Yes

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

Yes

If you have had any hospitalizations, please describe.

Do you have or have you ever had:

Rheumatic Fever or Rheumatic Disease?

Yes

Congenital Heart Disease?

Yes

Kidney Disease?

Yes

Diabetes?

Yes

Thyroid Disease?

Yes

Arthritis?

Yes

Stomach Ulcers or Colitis?

Yes

Glaucoma?

Yes

Osteoporosis?

Yes

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

Yes

Sinus or Nasal problems?

Yes

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

Yes

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

Yes

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

Yes

Seizures, Convulsions, Epilepsy, Fainting, Dizziness

Yes

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

Yes

Liver Disease: Jaundice, Hepatitis

Yes

Radiation from X-ray, Cancer Treatment Radiation

Yes

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

Yes

Are you using any of the following?

Antibiotics?

Yes

Anticoagulants (Blood Thinners)?

Yes

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

Yes

High Blood Pressure medications?

Yes

Steroids (Cortisone, Prednisone, etc.)?

Yes

Tranquilizers?

Yes

Insulin or Oral Anti-Diabetic drugs?

Yes

Digitalis, Inderal, Nitroglycerin or other heart drug?

Yes

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

Yes

Are you currently taking any antidepressant or anxiety medication?

Yes

Please list any and all medications taken, including prescription medications, diet drugs, over-the-counter medications, herbal or holistic remedies, vitamins, or minerals.

Do you smoke or chew Tobacco?

Yes

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

Yes

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

Yes

Have you ever had a bone density scan?

Yes

Have you had an HIV Blood test?

Yes

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

Yes

Describe any disease, condition, or problem not listed above.

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

Local Anesthesia (Novacain, etc.)?

Yes

Penicillin or other antibiotics?

Yes

Aspirin or Ibuprofen?

Yes

Codeine or other pain killers?

Yes

Latex or Rubber products?

Yes

Metal of any kind?

Yes

Food products?

Yes

Other allergies or reactions?

Yes

Other allergies or reactions? Please list

Women Only

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

Yes

Are you are using Oral Contraceptives?

Yes

Are you nursing?

Yes

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.

Signature of Responsible Party

Date

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