Patient Information Form For Dental Service - Primary Insurance
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1Bay Area Dental Office
W E L C O M E
We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have
questions we’ll be glad to help you. We look forward to working with you in maintaining your dental health.
Patient Information
Primary Insurance
Name
Subscriber Name________________________________
_____________________________________________
Last
First
Initial
Last
First
Relationship to Patient ∆
∆
∆
∆
Self
Spouse
Child
Other
Address
___________________________________________
City
State
Zip
Subscriber Birth date ______________
_______________________
_______
________
Home Phone
Cell Phone
Address
________________________
______________
______________
(if different from patient)
∆ Male ∆ Female
Sex:
City ___________________ State _______ Zip ________
______________
Birth date
Soc.Sec.#
Home Phone ______________ Cell Phone ____________
_________________
E-Mail Address: _____________________________________
Employed by
______________________________________
Insurance Company______________________________
∆
∆
∆
Occupation
_________________∆
Insurance Phone ________________ Group #
Single
Married
Child
Other
Business Address
__________________________________
__________
Business Phone
____________________
Is patient covered by additional insurance? ∆ Yes ∆ No
Notify in case of emergency
_________________________
Phone
_____________________
If yes, what is the insurance name? __________________
Who may we thank for referring you? ____________________
Medical History
Physician’s name ____________________________________ Phone ______________________
Date of last visit __________________
Have you had any serious illnesses or operations? ∆ Yes ∆ No
If yes, describe ___________________________________
Are you currently under physician care? ∆ Yes ∆ No
Have you ever had a blood transfusion? ∆ Yes ∆ No
Have you ever taken Fen-Phen/Redux ∆YES ∆NO
Women: Are you pregnant? ∆ Yes ∆ No
Nursing? ∆ Yes ∆ No
Taking birth control pills? ∆ Yes ∆ No
Please check ( √ ) yes or no whether you have had any of the following:
∆Y ∆N AIDS/HIV Positive
∆Y ∆N Anaphylaxis
∆Y ∆N Anemia
∆Y ∆N Arthritis,Rheumatism
∆Y ∆N Artificial Joints
∆Y ∆N Asthma
∆Y ∆N
∆Y ∆N Blood disease
Atopic (allergy prone)
∆Y ∆N Cancer
∆Y ∆N
∆Y ∆N Chemotherapy
∆Y ∆N Epilepsy
Chemical dependency
∆Y ∆N Back problems
∆Y ∆N Cough, Persistent
∆Y ∆N Cough up blood
∆Y ∆N Diabetes
∆Y ∆N Liver Malfunction
∆Y ∆N
∆Y ∆N Fainting
∆Y ∆N Heart murmur
Circulatory treatments
∆Y ∆N Jaw pain
∆Y ∆N Food allergies
∆Y ∆N Glaucoma
∆Y ∆N Headaches
∆Y ∆N High blood pressure ∆Y ∆N Nervous problems
∆Y∆N
∆Y ∆N Psychiatric care
Pacemaker/Heart surgery
∆Y ∆N Radiation treatment ∆Y ∆N Cortisone treatments ∆Y ∆N
∆Y ∆N Liver disease
Rapid weight gain or loss
∆Y ∆N Skin rash
∆Y ∆N Tuberculosis
∆Y ∆N
∆Y ∆N Shingles
Rheumatic/Scarlet fever
∆Y ∆N Shortness of breath ∆Y ∆N
∆Y ∆N Mitral Valve Prolepses
∆Y ∆N Swelling of feet
Artificial heart valves
∆Y ∆N Herpes
∆Y ∆N Pacemaker
∆Y ∆N Spinal Bifida
∆Y ∆N Stroke
∆Y ∆N Surgical implants
∆Y ∆N Respiratory disease
∆Y ∆N Skin rash
∆Y∆N
Hemophilia/Abnormal bleeding
∆Y ∆N Tobacco habit
∆Y ∆N Tonsillitis
∆Y ∆N Hepatitis
∆Y∆N
Allergic to Latex, Metal, chemical
∆Y ∆N Ulcer/Colitis
∆Y ∆N Venereal Disease
∆Y ∆N Heart problems, Describe:_______________________________
∆Y ∆N Kidney disease/malfunction
∆Y ∆N Thyroid disease or malfunction
Do you have any drug allergies? If yes, list all:
Are you currently taking any Medications? If yes, list all:
_____________________________________________________________
__________________________________________________________________
Authorization
I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be
used for the dentist to help determine appropriate and healthful dental treatment. If there are any changes in my medical history, I will inform the
dentist. I authorize the insurance company indicated on this form to pay the dentist all insurance benefits otherwise payable to me for services
rendered. I authorize the use of this signature on all insurance submissions. I authorize the dentist to release all information necessary to secure
the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.
Signature ________________________________________________________ Date ___________________
Payment is due in full at time of treatment, unless prior arrangements have been approved.
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