Click on Calendar, type the year 'YYYY' and pick the month & date.

*Patient Name :

Last name

Mid name

First name

I prefer to be called :

Birthday :

Age:

Gender : Male Female

*Address:

				City
State		Zip		APT#

*Email Address:

*Home phone #:

()- -

Social security#:

How did you hear about us?

Whom may we Thank for referring you?

Adult Patient Details

Marital Status :

Single Married Partnered Divorced/Separated Widowed

Cell phone #:

()- -

Work phone #:

()- - -

Employer Details

Employer :

Address :

				City
State		Zip		APT#

Occupation :

How long there ?

Relative or friend not living with you

His / Her name :

Relationship :

Work #:

()- - -

Home #:

()- -

Insurance information

Primary insurance

Dental coverage? YesNo

Insurance Co. name:

Address :

				City
State		Zip		APT#

Phone :

()- -

Group# (Plan, Local or Policy#):

Insured’s name :

Relationship :

Birthday :

Social security # :

Insured’s employer :

Address :

				City
State		Zip		APT#

Secondary insurance

Dental coverage? YesNo

Insurance Co. name:

Address :

				City
State		Zip		APT#

Phone:

()- -

Group# (Plan, Local or Policy#):

Insured’s name :

Relationship :

Birthday :

Social security # :

Insured’s employer :

Address :

				City
State		Zip		APT#

Medical History

Do you have a personal physician? YesNo

Physician’s Name :

Telephone #:

()- -

Date of last visit :

Your current physical health is : Good Fair Poor

Are you currently under the care of a physician? YesNo

Explain :

Have you been hospitalized in past 5 years? YesNo

Explain :

Have you ever had any surgical procedures? YesNo

Explain :

Have you had any artificial joints, metal rods, pins or implants placed? YesNo

Explain :

Do you usually pre medicate with antibiotics prior dental procedures? YesNo

Explain :

Do you smoke or use tobacco in any other form? YesNo

For women : Are you using a prescribed method of birth control ? YesNo

For women : Are you pregnant ? YesNo Week # :

For women : Are you nursing ? YesNo

Please list any serious medical condition(s) that you have ever had :

Please list any medications that you currently take :

List any medications/substances which have caused an allergic reaction

Aspirin

Codeine

Dental anesthetics

Erythromycin

Jewelry / Metals

Latex

Penicillin

Tetracycline

Dental history

Why have you come to the dentist today?

Why did you leave your previous dentist?

How can we accommodate you better during your dental visit?

Your current dental health is : Good Fair Poor

Date of last dental visit :

Last dental cleaning :

Last full mouth X-rays :

The information and preceding answers are true and correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or guardian to be necessary or advisable, including the use of local anesthesia and other medications as indicated. I agree that, regardless of insurance coverage, I am responsible for payment for services rendered. If I ever have any changes in my health or if my medication change I will, without fail, inform the doctor at my next appointment.

Notice of Privacy Practices

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.

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information.

As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations.

Treatment means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include teeth cleaning services.

Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.

Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information.

We may contact you to provide appointment reminders or information about treatment alternatives or other health- related benefits and services that may be of interest to you.

Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.

The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.

The right to reasonable request to receive confidential communication of protected health information from us by alternative means or at alternative locations.

The right to inspect and copy your protected health information.

The right to amend your protected health information.

The right to receive an accounting of disclosures of protected health information.

The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information.

This notice is effective as of *

and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.

You have recourse if you feel that your privacy protections have been violated. You have the right to file a written complaint with our office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice of the policies and procedures of our office. We will not retaliate against you for filing a complaint.

Please contact us for more information:
	For more information about HIPAA or to file a complaint: The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Ave. S.W. Washington, D.C. 20201 202-619-0257 or 1-877-696-6775
This is to verify I have read the Notice of Privacy Practices :