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Phone: (831) 688-7878

New Patient Information

 

The information provided on this form is important to your dental health. Please complete all of questions to the best of your ability. If there have been any changes in your health, please tell us. Questions are welcome and appreciated.

 

The security of your information is very important to us. This form is fully secure and your information will be protected. To learn more about the security measures used on this form, click the security logo to the right.

 

Patient Information

 

Patient First Name: *

Patient Middle Name:

Patient Last Name: *

Date of birth: *

  

SSN:

 

Mailing address: *

City: *

State: *

Zip: *

 

Home phone: *

Cell phone:

Patient Email: *

Preferred way to contact: *

Home phone Cell phone Email Work phone  

 

Check all that apply:

Male Female Married Single Minor  

Name of Spouse (if any):

Name of Guardian (if any):

Person responsible for this Account:

Relation to patient:

Emergency Contact Name:

Emergency Contact Phone:

How did you find our office?

 

Dental Insurance Information

Does the patient have dental insurance? *

Yes No  

 

Primary Insurance

Subscriber's Name:

Employer:

Insurance Company:

Insurance Company Phone #:

Insurance Company Address:

Group #:

ID #:

Subscriber's Birth Date:

Subscriber's Social Security #:

 

Health History

Please circle Y or N to indicate if you have experienced any of the following:

Cancer

Yes No  

Pacemaker

Yes No  

Chemical Dependancy

Yes No  

 

Asthma

Yes No  

Heart Infection

Yes No  

Mitral Valve Prolapse

Yes No  

 

Tuberculosis

Yes No  

Hepatitis

Yes No  

Artificial Valves/Joints

Yes No  

 

Diabetes

Yes No  

HIV/AIDS

Yes No  

Osteoporosis Medication

Yes No  

 

Tobacco Habit

Yes No  

High Blood Pressure

Yes No  

Women: Are You Pregnant?

Yes No  

 

Jaw Pain

Yes No  

Cortisone Treatment

Yes No  

Women: Taking Birth Control

Yes No  

 

Epilepsy

Yes No  

Chemotherapy

Yes No  

 

 

 

Please list serious illness or operations:

List all medications you are currently taking:

List any known allergies:

 

Authorization and Release

 

To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child ever have a change in health. By signing below, I am authorizing Dr. Christensen's office to bill my insurance for services rendered as a courtesy on my behalf. I am also acknowledging that it is exclusively my choice to undergo any dental procedure in this office and therefore, the full responsibility for all charges associated with any services rendered in this office is mine alone. Should my insurance fail to pay their contracted portion of any procedure in a timely manner (60 days), responsibility for the unpaid balance falls to me and it is my responsibility to follow up with my insurance company thereafter.

 

I also understand that payment is due in full at the time of treatment unless prior arrangements have been approved. Dr. Christensen may use my health care information and may disclose such information to my insurance company for the purposes of obtaining payment for services and for determining insurance benefits.

 

Signature of Patient, Parent, Guardian or Personal Representative

Today's Date:

 
 

Please wait, it may take a moment to submit your information.





Sam Christensen, DDS
General Practitioner

7545 Soquel Dr. Ste B
Aptos, CA 95003
(831) 688-7878

 

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