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Patient, Pharmacy and Insurance Information

Patient, Pharmacy and Insurance Information

Patient Information

Prefix:

Name:

Suffix:

Street:

City:

State:

Country:

Zip:

Preferred Phone #:

Is this a mobile number?

Email Address:

Date of Birth:

Sex:

Emergency Contact:

Emergency Phone #:

Primary Language:

Other:

Responsible Party

First Name:

Middle Name:

Last Name:

Street:

City:

State:

Country:

Zip:

Date of Birth:

Sex:

Responsible Party Signature:

Date:

Preferred Pharmacy

Name:

Phone Number:

Street:

City:

State:

Zip:

Primary Dental Insurance

Is subscriber the same as patient?

Subscriber Information:

First Name:

Middle Name:

Last Name:

Employer Name:

Insurance Company:

Ins Phone Number:

Subscriber ID/Policy Number:

Group/Contract Number:

Date of Birth:

Patient Relationship to Subscriber:

Subscriber SSN:

Secondary Dental Insurance

Is subscriber the same as patient?

Subscriber Information:

First Name:

Middle Name:

Last Name:

Employer Name:

Insurance Company:

Ins Phone Number:

Subscriber ID/Policy Number:

Group/Contract Number:

Date of Birth:

Patient Relationship to Subscriber:

Subscriber SSN:

Health History

Reason for Visit:

Other:

Height:

Weight:

Patient Date of Birth:

Are you under the care of a primary physician?

Primary Physician's Name:

Physician's Phone Number:

Date of Last Physical:

Other:

Are you taking or have you taken any steroid/cortisone therapy in the last 2 years?

Have you ever been hospitalized?

Are you taking or have you taken Oral Bisphosphonates (e.g., FOSAMAX, BONIVA) or IV Bisphosphonates, (e.g., ZOMETA, AREDIA)?

If Yes, How long?

Do you require antibiotics prior to dental procedures?

Are you allergic or have you had adverse reaction to any of the following?

Other:

List any medications you are taking including non-prescription drugs and herbals/vitamins:

Check any conditions that apply to you:

Dental History

Date of Last Dental Visit:

Other:

Date of Last Dental X-ray:

Other:

Oral Health

Have you ever been treated for periodontal (gum) disease?

Have you ever had Novocaine or other local anesthetic?

How happy are you with your smile (1-10)?

Are you currently wearing Dentures?

Age of dentures:

Please check any conditions that apply to you below:

Women Patients Only

Are you currently pregnant?

Estimated delivery Date:

Are you Nursing?

Are you taking any birth control prescriptions?

**NOTE Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth controls.

I certify that I have read and understand the above questions and acknowledge that questions have been answered to the best of my knowledge. I hereby give my consent to the dentist to perform an examination and diagnose my condition. I also give my consent for any preventive or basic restorative procedures which may be necessary. I understand that this consent will remain in effect until treatment is terminated either by me or the dentist.
​​​​​​​

Patient's Signature:

Date:

Dr's Signature/Medical History Review:

Date:

6 MONTHS UPDATE

Patient's Signature:

Date:

Dr's Signature/Medical History Review:

Date:

Patient Signatures

Release of Information to Insurers and Assignment of Benefits (must be signed by all patients with insurance and those who expect to obtain insurance)

To the extent permitted by law, I consent to my practices (or their designees) use and disclosure of my Protected Health Information to carry out payment activities in connection with my insurance claim. This information will be used exclusively for the purpose of evaluating and administering claims for benefits. I further authorize and direct payment to my practice of the dental benefits otherwise payable to me.

Signature:

Date:

(If the patient is a minor or disabled the Parent, Guardian or Attorney-in-Fact must sign and complete Responsible Party Section)

Authorization for Release of Health Records to External Parties (Optional)

I authorize the disclosure of information from my treatment records to:

Name of Recipient:

Relationship to the Patient:

I give authorization to disclose the following information:

Starting Date:

End Date:

Consent to obtain patient medication history (Optional)

To the extent permitted by applicable law, I authorize this dental practice (or their designees) to collect information about my prescription history from my pharmacy and insures (as applicable) and give my pharmacy and insurers permission to disclose such information. This includes prescription information related to medicines to treat AIDS/HIV and medicines used to treat mental health issues.

Signature:

Date:

Payment, Insurance and Financial Arrangement Policies (signed by ALL new patients)

By signing below, I acknowledge that I received the Financial Policies form and agree to abide by such policies.

Signature:

Date:

Notice of Privacy Practices

By signing below, I acknowledge that I have read the Notice of Privacy Practices, as mandated by the Health Insurance Portability and Accountability Act of 1996 ("HIPAA").

Signature:

Date:

(If the patient is a minor or disabled the Parent, Guardian or Attorney-in-Fact must sign and complete Responsible Party Section)

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