Existing Patient Insurance and Health Update

PATIENT REGISTRATION

Personal Information

Responsible Party First Name

Middle Initial

Last Name

Patient's Last Name

Middle Initial

Last Name

Address:

City

State

Zip

Home Phone #

Work Phone #

Cell Phone #

Email address

Emergency Contact

Add Additional Contact

Employer Information of Subscriber Insurance

Employer's Name

Phone Number

Address

City

State

Zip

If yes, Where?

Primary Insurance Information

If you do not know the following information please contact your insurance company by phone or internet.

Subscriber Name

Social Security

Date of Birth

Insurance Company

Plan Name

Phone Number

Address

City

State

Zip

Group Number

Policy Number

Payor ID / Number

Individual Deductible $

Individual yearly max $

Renewal Date

Secondary Insurance Information

Subscriber Name

Social Security

Date of Birth

Insurance Company

Plan Name

Phone Number

Address

City

State

Zip

Group Number

Policy Number

Payor ID / Number

Individual Deductible $

Individual yearly max $

Renewal Date

Referral Source

How did you hear about us ?

Dental insurance plans do not normally provide full coverage of your dental bill. Your dental coverage is a contract between you and your insurance company, and while we will cooperate to the fullest in expediting your claim, you are ultimately responsible for your account. Your portion of the bill will be due at time of service.

If your insurance has not paid within 60 days from the date from the date of service, we will look to you for prompt payment of the account. All costs for collection of the account, should collection procedures or small claims court become necessary, will be passed on to the patient and/or the responsible party.

I understand that, due to any false information, I will be subject to criminal prosecution

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient (Responsible party of minor)

Date

MEDICAL HISTORY FORM

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Are you under a physician's care now?

Yes No

If yes, Please explain

Have you ever been hospitalized or had a major operation?

Yes No

If yes, Please explain

Have you ever had a serious head or neck injury?

Yes No

If yes, Please explain

Are you taking any medications, pills or drugs?

Yes No

If yes, Please explain

Do you take, or have you taken, Phen-Fen or Redux?

Yes No

If yes, Please explain

Are you on a special diet?

Yes No

If yes, Please explain

Do you use tobacco?

Yes No

Do you use controlled substances?

Yes No

Women: Are you

Pregnant / Trying to get pregnant?

Yes No

Taking Oral Contraceptives?

Yes No

Nursing?

Yes No

Are you allergic to any of the following?

Aspirin

Penicillin

Codeine

Acrylic

Metal

Latex

Local Anesthetics

Other

If other, Please explain

If Others, Please explain

Comments

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information ca be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Signature of Patient, Parent or Guardian

Date

Your information will be encrypted.

Existing Patient Insurance and Health Update

PATIENT REGISTRATION

Personal Information

Emergency Contact

Employer Information of Subscriber Insurance

Primary Insurance Information

Secondary Insurance Information

Referral Source

MEDICAL HISTORY FORM

Women: Are you

Arizona Sunset Dental P.C.