Patient Questionnaire Form

PATIENT INFORMATION

Patient's Last Name

First

Middle

If not, what is your legal name?

Former Name

Birth Date

Age

Street address

SSN

Phone No.

City

State

Zip

Cell Phone No.

Email address

Employer

Employer Phone No.

Name of person, office, or other source referring you to our practice

Other family members seen here

RESPONSIBLE PARTY - INSURANCE INFORMATION

Responsible Party

Last name

First name

Email address

Home/Cell Phone No.

Street Address

City

State

Zip

Relationship to Patient

Add new row

IN CASE OF EMERGENCY

Name of local friend or relative (not living at same address)

Relationship to Patient

Home / Cell Phone No.

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Fantarella Dental Group or insurance company to release any information required to process my claims.

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.

Patient/Guardian signature

Date

Dental Medical History

Physician's Name

Date of last visit

Phone

Pharmacy

Phone

If yes, Please describe

Due Date?

Please indicate all medications now taking

Tobacco Use?

Have you ever had or been diagnosed with

Artificial Heart Valves

Previous Infective Endocarditis

Congenital Heart Disease

Cardiac Transplant

Have you ever had or been diagnosed with

Bleeding abnormally, with extractions or surgery

Heart Murmur

Mitral Valve Prolapse

Pacemaker

Rheumatic Fever

If other, Please indicate

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.

Insurance Assignment: I certify that I, and or my dependents(s) have insurance coverage with

Assign directly to

Fantarella Dental Group all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.

Authorization to Release Protected Health Information: I understand that there may be a need to consult with other health care providers. I voluntarily authorize Fantarella Dental to use and/or disclose my Protected Health Information (PHI) related to dental treatment. I authorize Fantarella Dental Group to receive and use the information

I understand that once the information is released it may be re-disclosed by the recipient and may no longer be protected by federal privacy regulations. I understand that I may revoke this authorization at any time by notifying, in writing, the above-named doctor disclosing the PHI. However, if I do revoke this authorization, it will not have any effect on any actions taken by the above-named doctor disclosing the PHI prior to their receipt of the revocation . I understand that my treatment cannot be conditioned on whether I sign this authorization. I understand I may refuse to sign this authorization.

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

Date

Your information will be encrypted.