Patient Information

Patient's Name

Preferred Name

Birth Date

SS No.

Prev. Visit.

Email address

Best Time to Call

Home Phone No.

Mobile Phone No.

Work Phone No.

Fax No.

Address 1

Address 2

City

State

Zip Code

Preferred Appointment times

Monday

Tuesday

Wednesday

Thursday

Morning

Afternoon

In an emergency who should be notified? Please enter Name and Phone number below:

Emergency Contact Person

Phone No.

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

Spouse or Responsible Party Information

Name

Preferred Name

Birth Date

Email address

Home Phone No.

Mobile Phone No.

Work Phone No.

Best time to call

Address 1

Address 2

City

State

Zip Code

Employment Information

The following is for:

the patient the person responsible for payment both not applicable

Employer Name

Phone No.

Address 1

Address 2

City

State

Zip Code

Primary Insurance Information

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Secondary Insurance Information

Add new row

Medical Health History Form

What is the reason for your visit today?

If yes, please explain

Name of your Physician

Phone No.

If you check "other" above, please specify

List all medications, supplements, and/or vitamins currently being taken: If none taken, enter none. *

If yes, please explain

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any changes in my health or medications, I will inform the doctors at the next appointment without fail.

Name of patient, parent or guardian completing this form

Relationship to patient

Consent for Services

As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed unless other arrangements are made.

Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1.0% per month (12% per annum) on the unpaid balance will be charged on all accounts exceeding 90 days.

I understand that any fee estimate for this dental care can only be extended for a period of three months from the date of the patient examination.

In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment.

THERE IS A $68.00 CHARGE FOR MISSED APPOINTMENTS WITHOUT 24 hr. NOTICE.

I have read the above conditions of treatment and payment and agree to their content.

Name of patient, parent or guardian completing this form

Relationship to Patient

Consent for Use and Disclosure of Health Information as Mandated by the Federal Government under the HEALTH INSURANCE PORTABILITY and ACCOUNTABILITY ACT OF 1995(HIPAA).

To the patient or guardian- Please read the following statements carefully:

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of privacy Practices before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice is available with this consent. We encourage you t read it carefully and completely before signing this consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

Right to Revoke: You have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Office Manager. Please understand that revocation of ths Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this consent.

I have had the full opportunity to read and consider the contents of this Consent Form and Notice of Privacy Practices. I understand that , by signing this Consent Form, I am giving my consent to you for use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations.

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 completing this form

Relationship to Patient

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