Name: Birth date
Address: City Zip Code
Home Phone: Cell Phone:
Driver’s License # SSN:
Check which applies: Single Married Divorced Separated
RESPONSIBLE PARTY INFORMATION (Please fill out if different from above)
Spouse or Parent/Guardian Name :
Relationship to Patient?
Who should we contact in case of emergency?
Number to contact:
Whom may we thank for referring you?
DENTAL INSURANCE INFORMATION
Name of Insured Birth Date
Relationship to Patient Insurance Comp
Insurance Phone Insurance ID# or SSN
SECONDARY DENTAL INSURANCE INFORMATION (if applicable)
Name of Insured Birth Date Employer
Relationship to Patient Insurance Comp
Insurance Phone Insurance ID# or SSN Group
If yes, what?
If yes please list
Other allergies not listed above:
WOMEN: Are you taking oral contraceptives? Yes No Are you pregnant? Yes No
Please check any conditions you currently have or have had :
|AIDS/ HIV Positive||Cold Sores||Glaucoma||Irregular Heartbeat||Scarlet Fever|
|Alzheimer’s Disease||Congenital Heart Disorder||Hay Fever||Kidney Problems||Shingles|
|Anaphlylaxis||Convulsions||Heart Attack/Failure||Leukemia||Sickle Cell Disease|
|Anemia||Cortisone Meds||Heart Murmur||Liver Disease||Sinus Trouble|
|Angina||Diabetes||Heart Pace Maker||Low Blood Pressure||Spina Bifida|
|Arthritis||Drug Addiction||Heart Trouble/Disease||Lung Disease||Stomach/Intestinal Problems|
|Artificial Heart Valves||Easily Winded||Hemophilia||Mitral Valve Prolapse||Stroke|
|Artificial Joints||Emphysema||Hepatitis A||Pain in Jaw Joints||Swelling of LImbs|
|Asthma||Epilepsy /Seizures||Hepatitis B||Parathyroid Disease||Thyroid Disease|
|Blood Disease||Excessive Bleeding||Hepatitis C||Psyciatric Care||Tonsillitis|
|Blood Transfusion||Excessive Thirst||Herpes||Radiation Treatment||Tuberculosis|
|Breathing Problems||Fainting /Dizziness||High Blood Pressure||Recent Weight Loss||Tumors/Growths|
|Bruise Easily||Frequent Cough||High Cholesterol||Renal Dialysis||Ulcers|
|Cancer||Frequent Diarrhea||Hives or Rash||Rheumatic Fever||Venereal Disease|
|Chemotherapy||Frequent Headaches||Hypoglycemia||Rheumatism||Yellow Jaundice|
Have you ever had any serious illness not listed above?
Patient Signature ________________________________ Date:
Please check yes/no next to each listed condition to indicate if anyone in your immediate family (parents or siblings) have or have had it.
If they have, please indicate the person's relationship to you. i.e. mother
Periodontal (Gum) Disease
High Blood Pressure
Pancreatic and or Kidney Cancer
Head or neck cancer
|How would you rate the condition of your mouth? Excellent Good Fair Poor|
|Previous Dentist How long were you a patient?|
|Date of most recent dental exam Date of most recent xrays|
|Date of most recent treatment (other than a cleaning)|
|I routinely see my dentist every 3mos. 4 mos. 6 mos. 12 mos. Not routinely|
|What is your immediate concern?|
To our patients without insurance:
**A $3.00 billing fee will be added to your balance if statements are sent out. If the account becomes past due and turned over to collections, you agree to reimburse us the fees of any collection agency, which may be based on a percentage at a maximum of 30% of the debt, and all costs, and expenses, including reasonable attorneys’ fees, we incur in such collections efforts. Your account being turned over to collections may result in you and anyone associated with this account being dismissed from the practice.
I understand and agree to the above policy:
HIPAA PRIVACY FORM
HIPAA OMNIBUS RULE
PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM
You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.
The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.
MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITYS IN THE FUTURE.
PLEASE PRINT YOUR NAME: PLEASE SIGN YOUR NAME:
DESCRIPTION OF AUTHORITY:
HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA?
First Name Only Proper Sir Name Other
PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes step parents, grandparents and any care takers who can have access to this patient’s records):