NEW PATIENT REGISTRATION PACKET

PATIENT REGISTRATION

ID:

Chart ID:

First Name:

Last Name:

Middle Initial:

Patient Is:

Policy Holder Responsible Party

Preferred Name:

Email:

Responsible Party (if someone other than the patient)

First Name:

Last Name:

Middle Initial:

Address:

Address 2:

City:

State:

Zip:

Pager:

Home Phone:

Work Phone:

Ext.:

Cellular:

Sex:

Male Female

Marital Status:

Married Single Divorced Separated Widowed

Birth Date:

Age:

Soc. Sec:

Drivers Lic:

Please select:

Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder

Patient Information

First Name:

Last Name:

Middle Initial:

Address:

Address 2:

City:

State:

Zip:

Pager:

Home Phone:

Work Phone:

Ext:

Cellular:

Sex:

Male Female

Marital Status:

Married Single Divorced Separated Widowed

Birth Date:

Age:

Short text field

E-mail:

I would like to receive correspondences via e-mail.

Section 2

Employment Status:

Full Time Part Time Retired

Student Status:

Full Time Part Time

Medicaid ID:

Pref. Dentist:

Employer ID:

Pref. Pharmacy:

Carrier ID:

Pref. Hyg.:

Section 3

Additional Comments:

Primary Insurance Information

Name of Insured:

Relationship to Insured:

Self Spouse Child Other

Insured Soc. Sec:

Insured Birth Date:

Employer:

Address:

Address 2:

City:

State:

Zip:

Ins. Company:

Address:

Address 2:

City:

State:

Zip:

Rem. Benefits:

Rem. Deduct:

Secondary Insurance Information

Name of Insured:

Relationship to Insured:

Self Spouse Child Other

Insured Soc. Sec:

Insured Birth Date:

Employer:

Address:

Address 2:

City:

State:

Zip:

Ins. Company:

Address:

Address 2:

City:

State:

Zip:

Rem. Benefits:

Rem. Deduct:

MEDICAL HISTORY

PATIENT NAME:

Date field

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:

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Yes No

If yes, please explain:

Are you on a special diet?

Yes No

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

Local Anesthetics

Acrylic

Metal

Latex

Sulfa drugs

Other

If yes, please explain:

AIDS/HIV Positive

Yes No

Alzheimer's Disease

Yes No

Anaphylaxis

Yes No

Anemia

Yes No

Angina

Yes No

Arthritis/Gout

Yes No

Artificial Heart Valve

Yes No

Artificial Joint

Yes No

Asthma

Yes No

Blood Disease

Yes No

Blood Transfusion

Yes No

Breathing Problem

Yes No

Bruise Easily

Yes No

Cancer

Yes No

Chemotherapy

Yes No

Chest Pains

Yes No

Cold Sores/Fever Blisters

Yes No

Congenital Heart Disorder

Yes No

Convulsions

Yes No

Cortisone Medicine

Yes No

Diabetes

Yes No

Drug Addiction

Yes No

Easily Winded

Yes No

Emphysema

Yes No

Epilepsy or Seizures

Yes No

Excessive Bleeding

Yes No

Excessive Thirst

Yes No

Fainting Spells/Dizziness

Yes No

Frequent Cough

Yes No

Frequent Diarrhea

Yes No

Frequent Headaches

Yes No

Genital Herpes

Yes No

Glaucoma

Yes No

Hay Fever

Yes No

Heart Attack/Failure

Yes No

Heart Murmur

Yes No

Heart Pacemaker

Yes No

Heart Trouble/Disease

Yes No

Hemophilia

Yes No

Hepatitis A

Yes No

Hepatitis B or C

Yes No

Herpes

Yes No

High Blood Pressure

Yes No

High Cholesterol

Yes No

Hives or Rash

Yes No

Hypoglycemia

Yes No

Irregular Heartbeat

Yes No

Kidney Problems

Yes No

Leukemia

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Lung Disease

Yes No

Mitral Valve Prolapse

Yes No

Osteoporosis

Yes No

Pain in Jaw Joints

Yes No

Parathyroid Disease

Yes No

Psychiatric Care

Yes No

Radiation Treatments

Yes No

Recent Weight Loss

Yes No

Renal Dialysis

Yes No

Rheumatic Fever

Yes No

Rheumatism

Yes No

Scarlet Fever

Yes No

Shingles

Yes No

Sickle Cell Disease

Yes No

Sinus Trouble

Yes No

Spina Bifida

Yes No

Stomach/Intestinal Disease

Yes No

Stroke

Yes No

Swelling of Limbs

Yes No

Thyroid Disease

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Tumors or Growths

Yes No

Ulcers

Yes No

Venereal Disease

Yes No

Yellow Jaundice

Yes No

Have you ever had any serious illness not listed above?

Yes No

If yes, please explain:

Comments:

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

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.

NAME OF PATIENT, PARENT, or GUARDIAN:

DATE:

General Dentistry Informed Consent

Please initial by the proposed and accepted treatment:

1. Treatment to be rendered

I understand that I am having the following treatment performed:

X‐rays

Prophylaxis

Periodontal Procedures

Fillings

Crown & Bridges

Extractions

Dentures

Partial

Other

If Other, please specify:

2. Drugs and Medications

I understand that antibiotics, analgesics and other medications that I may be prescribed can cause allergic reactions, including but not limited to redness and swelling of tissues, pain, itching, vomiting and/or anaphylactic shock death, a severe allergic reaction. I also understand that these medications interfere with the effectiveness of contraceptives.

3. Changes in Treatment Plan

I understand that during treatment it may be necessary to change or add procedures that were not discovered during my examination. For example, if complications arise after a routine restorative procedure, root canal therapy may be necessary. I give my permission to the dentist to make changes and/or additions as necessary, upon oral or written explanation to me.

4. Removal of Teeth

I understand that procedures such as root canal therapy, placement of crowns and periodontal surgery, may be options for treatment. However, I believe removing the infected tooth is the best option and I authorize the dentist to remove the tooth listed below. I understand that removing a tooth does not always remove all infection, if present, and it may be necessary to have further treatment. The risks involved in having a tooth removed include, but are not limited to pain, swelling, spread of infection, dry socket, fractured jaw, or loss of sensation in the teeth, tongue and surrounding tissue (paresthesia). These risks can last for an indefinite period of time. I also understand that I may need further treatment by a specialist if complications arise during or following treatment and I responsible for additional specialist fees.

Tooth for removal:

5. Dentures

I understand that dentures may cause core spots, altered speech and difficulty when eating. I realize that receiving dentures immediately after extractions may be painful and may require considerable adjustment and several relines. A permanent reline, which is not included in the denture fee, will be necessary later.

I understand that the denture try‐in appointment gives me the opportunity to approve the cosmetic appearance of my dentures. I know it is my responsibility to look closely at the size, shape, color, fullness and arrangement of my dentures. I understand failure to keep any appointment may result in a poor fitting of my dentures. I realize that if I delay my appointment for more than 30 days, there will be additional charges to my account. Any changes made after my dentures are complete will result in an additional fee.

Radio buttons

Option 1 Option 2

6. Endodontic Treatment (Root Canal)

I realize there is no guarantee that root canal treatment will save my tooth, and that complications can occur from treatment, and that occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily affect the success of the treatment, I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy)

7. Periodontal Loss (Tissue & Bone)

I understand that I have serious condition, causing gum and bone infection or loss and that it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. I understand that undertaking any dental procedures may have a future adverse effect on my periodontal condition.

I have read and understand the information above. I have received adequate information about proposed treatment: I understand the treatment, and all questions have been fully answered. I also understand that it is my responsibility to work with the administrative and clinical staff to establish and keep appointments to allow sufficient time for recommended procedures.

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.

Name of Patient/Parent:

Date:

We appreciate your input!!!

Referral by an existing patient of ours:

Your Insurance Company:

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it.

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; examining your teeth; prescribing medications and faxing them to be filled; referring you to another doctor or clinic for other health care or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or dental care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). "Health care operations" mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.

We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we will ask you for special written permission.

EDIT: We will ask for special written permission in the following situations

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

when a state or federal law mandates that certain health information be reported for a specific purpose;
for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;
disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
uses or disclosures for health related research;
uses and disclosures to prevent a serious threat to health or safety;
uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service;
disclosures of de-identified information;
disclosures relating to worker's compensation programs;
disclosures of a "limited data set" for research, public health, or health care operations;
incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;
disclosures to "business associates" who perform health care operations for us and who commit to respect the privacy of your health information;

Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your dental care.

APPOINTMENT REMINDERS

We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.

OTHER USES AND DISCLOSURES

We will not make any other uses or disclosures of your health information unless you sign a written "authorization form." The content of an "authorization form" is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it's your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION

The law gives you many rights regarding your health information. You can:

ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person at the address, fax or E Mail shown at the beginning of this Notice.
ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using E mail to your personal E Mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.

OUR NOTICE OF PRIVACY PRACTICES

By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Web site.

COMPLAINTS

If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.

PRIVACY PRACTICE ACKNOWLEDGEMENT

ACKNOWLEDGEMENT FORM

I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.

Name:

Birthdate:

Date:

I authorize any medical, test results, treatment plans and other health information released or discussed with authorized personnel:

Please select:

do don't

want messages left on my machine or with person(s) concerning appointment scheduling, lab cases or billing.

Initials