NEW PATIENT FORM

If you are a new patient, uploading your Driver’s License/Government Issued Photo ID and your Insurance Card will ensure the check-in process for your first appointment will be as quick as possible.

If you forgot to bring your dental insurance card. Ask our receptionist for assistance.

Carry Your Insurance Card

Your insurance card is essential. When you check in with the dental office reception, you will likely be asked for your dental insurance card. If you forget to carry your dental insurance card:

You can access your dental insurance card and coverage information by calling or electronically by logging in online. And get a copy/screenshot of your insurance card.

Inform the dentist receptionist immediately as soon as you check in. They will allow you to email your insurance card copy to yourdentistforms@gmail.com for your dentist to bill your dental insurance. Why do you need a dental insurance ID card when you visit your dentist?

It is recommended. Your ID card tells your dentist the plan you're enrolled in to ensure you're charged the correct co-payment. They were significantly needed if your employer changed your dental insurance plan since your last visit.

In case your dental insurance denies your dental claim. You or your dentist can appeal to the California Department of Insurance and One of the supporting documents.

HEALTHCARE PROVIDER REQUEST FOR ASSISTANCE (HPRFA) http://www.insurance.ca.gov/01-consumers/101-help/upload/RFAhealth.pdf

Needed are copies of your Dental Insurance card.

That is why you must always have proof of dental insurance in your possession. INSTRUCTIONS

1. With your smartphone, take a picture of the front and back of your Photo ID and Insurance Card prior to starting this form.

2. To upload your images, click the “Choose a file” button and locate "Photo library" on the image on your phone.

3. Do not use the “Take Photo or Video” feature within the form.

4. To ensure your images upload properly, take the photos BEFORE you start the form. Do not use the “Take Photo” feature within the form. Except in SELFIE UPLOAD BUTTON

Contact our office at 510-792-4525 (Newark)

if you have any questions. Or ask the Receptionist to help fill up these forms while waiting for your appointment

NOTE: Your files are fully encrypted with HIPAA-compliant software to ensure security and privacy.

Enter Full Name *

First

Last

Birthday *

Phone *

Patient E-mail *

Address / City / State / Zip Code *

Address Line 1

Address Line 2

City

State

Zip Code

PLEASE SELECT FROM THE DROPDOWN MENU

Gender *

PLEASE SELECT FROM THE DROP DOWN MENU

Civil Status *

PLEASE SELECT FROM THE DROP DOWN MENU

Patient Alt. Phone #1

Alt. Phone#2

Patient Employer/ School *

Patient Employer/ School Phone *

Patient Employer/ School Address / City / State / Zip Code *

Patient Spouse / Parent’s Name

Patient Spouse Employer

Patient Spouse Work Phone

Person to contact in case of emergency *

Phone to contact in case of emergency *

NAME OF PERSON RESPONSIBLE FOR THIS ACCOUNT *

Relationship to Patient *

PLEASE SELECT FROM THE DROP DOWN MENU

Name of Insured / Policy Holder *

Birthdate *

Relationship to Patient *

PLEASE SELECT FROM THE DROP DOWN MENU

Social Security # *

Insurance Subscriber ID # *

Employer *

Date Employed

Work Phone *

Employer Address / City / State / Zip Code *

Insurance Company *

Insurance Address / City/ State / Zip Code *

How much is your deductible?

How much have you used?

Max. Annual Benefit *

PLEASE UPLOAD ANY PRIMARY DENTAL INSURANCE ID (FRONT) *

Click or drag a file to this area to upload.

WAIT FOR THE PHOTOS TO UPLOAD COMPLETELY BEFORE CLICKING NEXT BUTTON

PLEASE UPLOAD ANY PRIMARY DENTAL INSURANCE ID (BACK) *

Click or drag a file to this area to upload.

WAIT FOR THE PHOTOS TO UPLOAD COMPLETELY BEFORE CLICKING NEXT BUTTON

DO YOU HAVE SECONDARY INSURANCE? *

PLEASE SELECT FROM THE DROP DOWN MENU

Reason for today’s visit *

Date of last dental care *

Former Dentist *

Date of last dental X-rays *

Previous Dentist Address *

How often do you floss? *

How often do you brush? *

Medical Physician’s Name *

Date of last visit *

Have you ever used a bisphosphonate medication? Common brand name are Fosamax, Actonel, Atelvia, Didronel, Boniva. *

Have you ever taken any of the group of drugs collectively referred to as “fen-phen”? These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). Yes No Have you had any serious illness or operations? If yes, describe *

Have you ever had a blood transfusion? If yes, give approximate dates *

(Women) Are you pregnant? Nursing?

Taking birth control pills?

Do you have a latex allergy? *

List medications you are currently taking and correlating diagnosis : *

Allergies: *

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. *

YES

I certify that I, and/or my dependent(s), have insurance coverage with *

PLEASE SELECT FROM THE DROP DOWN MENU

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 submission The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Companies And their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable fore related Services. This consent will end when the current treatment plan is completed or one year from the date signed below. *

YES

Payment is due in full at time of treatment unless prior arrangements have been approved. *

YES

DATE SIGNED *

Date

Time

PLEASE TYPE OR ENTER NAME of Patient, Parent, Guardian or Personal Representative *

Signature *

ROTATE YOUR PHONE TO ENTER FULL SCREEN

PLEASE UPLOAD ANY GOVERNMENT VALID ID (FRONT) *

Click or drag a file to this area to upload.

WAIT FOR THE PHOTOS TO UPLOAD COMPLETELY BEFORE CLICKING SUBMIT BUTTON

PLEASE UPLOAD ANY GOVERNMENT VALID ID (BACK) *

Click or drag a file to this area to upload.

WAIT FOR THE PHOTOS TO UPLOAD COMPLETELY BEFORE CLICKING SUBMIT BUTTON

UPLOAD SELFIE *

Click or drag a file to this area to upload.

WAIT FOR THE PHOTOS TO UPLOAD COMPLETELY BEFORE CLICKING SUBMIT BUTTON

OTHER PHOTOS IF NEEDED

Click or drag a file to this area to upload.

WAIT FOR THE PHOTOS TO UPLOAD COMPLETELY AND CLICK SUBMIT BUTTON

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WARNING! NEVER FAKE YOUR SIGNATURE!

If charged as a misdemeanor, the defendant can be sentenced to up to a year in jail, restitution to the victim and substantial court fines. If charged as a felony, the defendant can potentially be sentenced to up to three years in prison, in addition to fines and restitution.