ID: PATIENT REGISTRATION DATE First Name: Patient Is: Policy Holder Responsible Party Last Name: Preferred Name: Middle Initial: Responsible Party (if someone other than the patient) First Name: Last Name: Middle Initial: Address 2: Email: Home Phone: Work Phone: Ext: Cellular: Birth : Soc Sec: Drivers Lic: Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder Patient Information Address 2: City: State / Zip: Pager: Home Phone: Work Phone: Ext: Cellular: Sex: Male Female Marital Status: Married Single Divorced Separated Widowed Birth : Age: Soc Sec: Drivers Lic: E-mail: I would like to receive correspondences via e-mail. Employment Status: Section 2 Section 3 Full Time Part Time Retired Referred By Previous Dentist Emergency Contact Student Status: Full Time Part Time Medicaid ID: Employer ID: Carrier ID: Pref. Dentist: Pref. Pharmacy: Pref. Hyg: Emergency Contact # Primary Insurance Information Name of Insured: Relationship to Insured: Self Spouse Child Other Insured Soc. Sec: Insured Birth : Employer: Address 2: Rem. Benefits: Rem. Deduct: Ins. Company: Member ID: Address 2: Secondary Insurance Information Name of Insured: Insured Soc. Sec: Employer: Insured Birth : Relationship to Insure d: Self Spouse Child Other Ins. Company: Address 2: Address 2: Rem. Benefits: Rem. Deduct:
Time Patient Name: Birth : Medical History Created: 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, can affect your dental treatment Are you under a physician's care now? O Yes O No If yes Have you ever been hospitalized or had a major operation? O Yes O No If yes Have you ever had a serious head or neck injury? O Yes O No If yes Are you taking any medications, pills, or drugs? O Yes O No If yes Do you take1 or have you taken, Phen-Fen or Redux? O Yes O No If yes Have you ever taken Fosamax, Boniva, Actonel or any other O Yes O No If yes medications containing bisphosphonates? Are you on a special diet? O Yes O No Do you use tobacco? O Yes O No Do you use controlled substances? O Yes O No If yes Women: Are you... O Pregnant/trying to get pregnant? O Nursing? O Taking oral contraceptives? Are you allergic to any of the following? O Aspirin O Pencillin O Codeine O Acrylic O Metal O Latex O Sulfa Drugs O Local Anesthetics Other? O If yes Do you have, or have you had, any of the following? AIDS/HIV Positive Alzheimer's Disease Cortisone Medicine Diabetes Hemophili Hepatitis A Radiation Treatments Recent Weight loss Anaphylaxis Drug Addiction Hepatitis B or C Renal Dialysis Anemia Easily Winded Herpes Rheumatic Fever Angina Emphysema High Blood Pressure Rheumatism Arthritis/Gout Epilepsy or Seizures High Cholesterol Scarlet Fever Artificial Heart Valve Excessive Bleeding Hives or Rash Shingles Artificial Joint Excessive Thirst Hypoglycemia Sickle Cell Disease Asthma Fainting spells/dizziness Irregular Heartbeat Sinus Trouble Blood Disease Frequent Cough Kidney Problems Spina Bifida Blood Transfusion Frequent Diarrhea Leukemia Stomach/Intestinal Breathing Problems Frequent Headaches Liver Disease Disease Stroke Bruise Easily Genital Herpes Low Blood Pressure Swelling of Limbs Cancer Glaucoma Lung Disease Thyroid Disease Chemotherapy Hay Fever Mitral Valve Prolapse Tonsillitis Chest Pains Heart Attack/Failure Osteoporosis Tuberculosis Cold Sores/Fever Blisters Heart Murmur Pain in Jaw Joints Tumors or Growths Congenital Heart Disorder Heart Pacemaker Parathyroid Disease Ulcers Convulsions Heart Trouble/Disease Psychiatric Care Venereal Disease Yellow Jaundice Have you ever had any serious illness not listed above? If yes 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. Signature of Patient, Parent or Guardian: X : _
AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION PLEASE PRINT CLEARLY Patient Name Address City, State ZIP Today's of Birth Phone Email Patient Authorization I,, hereby authorize Smiles 4 All Dental to release, use and/or disclose my protected health information as directed below. Health Information This Authorization pertains to the following types of protected health information about me: All dental records received or created by Smiles 4 All Dental Dental report(s) (please specify) Dental image(s) (please specify) All dental records relating to (specify injury or condition) Other (please describe) Release Information Please release my health information to: Organization Contact Address City, State ZIP Phone Email Fax Handling Notes I understand that, per my voluntary request, this Authorization permits Smiles 4 All Dental to release, use or disclose my protected health information for purposes other than payment, treatment, or healthcare operations as defined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its corresponding regulations. I further understand that I may revoke this Authorization at any time by providing written notification to Smiles 4 All Dental. Revocation of this Authorization will be effective on the date notice is received and processed by Smiles 4 All Dental except to the extent that action has already been taken in reliance upon this Authorization. Authorization Expiration This Authorization will expire one (1) year from the date that I sign it, unless I indicate an alternative expiration date below: Enter Alternative Expiration :, 20 www.smiles4alldental.com Page 1 of 2
AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION Know Your Rights Your decision to sign this Authorization is voluntary. Smiles 4 All Dental will not refuse treatment to you if you refuse to sign this Authorization. When your protected health information is released as provided by this Authorization, please be aware that the named recipient (above) may not be legally obligated (under HIPAA) to obtain an authorization for subsequent re-disclosure of your protected health information. Patient Signature I have read the contents of this Authorization, and I confirm that the contents are consistent with my directions. I understand that by signing this Authorization, I am permitting Smiles 4 All Dental to release, use or disclose my protected health information. Signature Print Name Witness (Optional) Representative Signature I affirm that I am the personal representative of the patient noted above and that I have the authority to authorize the release, use or disclosure of the patient's protected health information on his/her behalf. I have read the contents of this Authorization, and I confirm that the contents are consistent with my directions. I understand that by signing this form, I am authorizing, on behalf of the patient, the release, use or disclosure the patient's protected health information. Signature Print Name Relationship to Patient Parent Guardian Power of Attorney FOR OFFICE USE ONLY Received By Patient ID www.smiles4alldental.com Page 2 of 2
ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES Acknowledgement I, _, hereby acknowledge that I have received and reviewed a copy of Smiles 4 All Dental's HIPAA Notice of Privacy Practices. I understand that Smiles 4 All Dental's HIPAA Notice of Privacy Practices may change periodically and that I am entitled to receive a copy of Smiles 4 All Dental's revised HIPAA Notice of Privacy Practices upon request. I understand that, if I have questions about Smiles 4 All Dental's HIPAA Notice of Privacy Practices, I may contact Dr. Veena Madhure, DDS 925-523-3864 I understand that it is my right to refuse to sign this Acknowledgement should I so choose, and that Smiles 4 All Dental will not refuse treatment to me if I refuse to sign this Acknowledgement. I further understand that I may contact the Secretary of the U.S. Department of Health and Human Services should I have concerns regarding Smiles 4 All Dental's privacy policies and procedures. For information on how to contact the U.S. Department of Health and Human Services, please ask Dr. Veena Madhure, noted above, for assistance. Patient Signature Signature of Personal Representative Print Name of Personal Representative Relationship of Personal Representative to Patient FOR OFFICE USE ONLY Smiles 4 All Dental made a good-faith effort to obtain Acknowledgement, from the patient noted above, of receipt of its HIPAA Notice of Privacy Practices. In spite of these efforts, Smiles 4 All Dental was unable to obtain a signed Acknowledgement for the following reason(s): Refusal to sign Acknowledgement on _, 20. Communications barriers prohibited us from obtaining a signed Acknowledgement. An emergency situation prohibited us from obtaining a signed Acknowledgement. Other (Describe): Received By Patient ID www.smiles4alldental.com
PATIENT GENERAL CONSENT FORM I,, consent to be a patient at Smiles 4 All Dental and agree to a radiographic and clinical examination. I also understand and consent to the following: 1. During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges, and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, pediatric dentistry, and radiography. 2. I will provide a thorough and complete medical history, supply a full list of my medications with dosages, and consent to my dentist communicating with my other medical practitioners to inquire about any aspect of my health history. 3. No guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results. 4. I will pay in full any cost of treatment or insurance copayments according to the office s financial policy. I understand that even if insurance pre-estimate is given or a procedure has been preapproved, I am responsible for any costs that my insurance does not cover. 5. My treatment plan may change at any time and I will do my best to approach my dental care with optimism and open communication with my dentist, hygienist, and dental office staff. 6. I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about. Patient or Guardian Signature Witness www.smiles4alldental.com