New Patient Forms

Patient's Last Name

First Name

Middle

Present Address

City

State

Zip

How Long at This Address

Cell Phone No.

Home Phone No.

Work Phone No.

Previous Address (if less than 2 years at present address)

City

State

Zip

Patient's Occupation

Employer

How long emp.?

Responsible Party and Bill Account to: Name

Billing Address

City

State

zip

Patient's Date of Birth

If married, spouse's name

Cell Phone No.

Spouse's Employer

How Long Employed?

Work Phone No.

Employer's Address

City

State

Zip

Father's Name (If Child)

Occupation

Cell Phone No.

Mother's Name (If Child)

Occupation

Cell Phone No.

Relative Not Living at Same Address: Name

Relationship

Contact No.

I was referred by

Has any member of your immediate family ever been examined or treated by Dr. Gerard

Yes No

If yes. Name

Relationship

DENTAL INSURANCE COVERAGES

Dental Insurance Carrier

Group No.

Member ID No.

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

MEDICAL HISTORY

Patient's Name

Birthdate

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.

If yes, please explain

WOMAN: ARE YOU?

Are you allergic to any of the following?

Aspirin

Penicillin

Codeine

Local Anesthetic

Acrylic

Metal

Latex

Sulfa Drugs

Other

If Check, Please Explain

Have you ever had any serious illness not listed above? (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.

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 OF PATIENT, PARENT, OF GUARDIAN

DATE

DENTAL HEALTH

Patient's name

Birth Date

Previous Dentist

Address

City

State

Zip

Date of Last Appointment

Why did you leave your previous dentist?

When was the last time you had your teeth cleaned?

How often do you brush?

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 of Patient, Parent, or Gaurdian

Date

PATIENT AUTHORIZATION FORM TO GIVE MEDICAL INFORMATION

hereby authorize Gerard M. Beyt, D.D.S. and Staff, to give the following people information concerning my health and well being.

Add Additional Names

The following information may be given to the above individuals

Appointment Date and Time

Medications

Procedures

Leave a message on answering machine about any above information

Any other information regarding my Dental Health

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.

Signed:

Date

Witness

Date

Due to HIPAA Regulations, Dr. Gerard M. Beyt will not release any personal or medical information that you give unless we have a written authorization from you to do so. All information is kept confidential.

PATIENT CONSENT FORM

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

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 Name / Signature

Relationship to Patient

Date

CONSENT FOR PURPOSES OF TREATMENT I PAYMENT AND HEALTHCARE OPERATIONS

I consent to the use or disclosure of my protected health information by Gerard M. Beyt, D.D.S. for the purpose of diagnosing or providing treatment to me, obtaining payment for my health care bills or to conduct health care operations. I understand.that diagnosis or treatment of me by Dr. Beyt may be conditioned upon my consent as evidenced by my signature on this document.

I understand I have the right to request a restriction as to how my protected health information is used or disclosed to carry out treatment, payment, or healthcare operations for the practice. Dr. Beyt is not required to agree to the restrictions that I may request. However, if Dr. Beyt agrees to a restriction that I request, the restriction is binding to Dr. Beyt.

I have the right to revoke this consent, in writing, at any time, except to the extent that Dr. Beyt has taken action is reliance on the consent.

My "protected health information" means health information, including demographic information, collected from me, and created for received by my physician, another healthcare provider, a health plan, my employer, or a health care clearinghouse. This protected health information relates to my past, present, or future physical or mental health or condition and identifies me, or there is a reasonable basis to believe the information may identify me.

I understand I have a right to review Dr. Beyt's Notice of Privacy Practices prior to signing this document. Dr. Beyt's Notice of Privacy Practices has been provided to me. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that will occur in my treatment, payment of my bills, or in the performance of health care operations of Dr. Beyt. The Notice of Privacy Practices for Dr. Beyt is also provided in the office waiting room. This notice of Privacy Practices also describes my rights and Dr. Beyt's duties with respect to my protected health information.

Dr. Beyt reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. I may obtain a revised notice of privacy practices by calling the office and requesting a revised copy be sent in the mail, or asking for one at the time of my next appointment.

This consent will be retained for six years from the date of signature.

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 / Signature of Patient

Date

Your information will be encrypted.