Step 1 of 4 25% WelcomeFirst Name(Required) Last Name(Required) ContactNickname Address(Required) City(Required) State(Required)AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip(Required) Gender(Required)MaleFemaleOtherPrefer not to answerDate of Birth(Required) MM slash DD slash YYYY Age(Required) Cell Phone(Required)Email(Required) OtherHow did you hear about our office? Family Members treated in our office Reason for consultation? Previous Dentist Date of last cleaning MM slash DD slash YYYY Responsible PartyIs someone other than yourself the responsible party? Yes No Insurance (if applicable)Company Subscriber/Member ID Medical/Dental HistoryAIDS Yes No Alzheimer's/Dementia Yes No Anemia Yes No Arthritis Yes No Artificial Heart Valves Yes No Artificial Joints Yes No Asthma Yes No Back Problems Yes No Blood Disease Yes No Cancer Yes No Chemical Dependency Yes No Chemotherapy Yes No Circulatory Problems Yes No Cortisone Treatments Yes No Coughing, Persistent Yes No Cough up Blood Yes No Diabetes Yes No Epilepsy Yes No Fainting Yes No Glaucoma Yes No Headaches Yes No Heart Murmer Yes No Heart Problems Other Yes No Hemophilia Yes No Hepatitis Yes No High Blood Pressure Yes No HIV Positive Yes No Jaw Pain Yes No Kidney Disease Yes No Liver Disease Yes No Low Blood Pressure Yes No Mitral Valve Prolapse Yes No Nervous Disorders Yes No Pacemaker Yes No Psychiatric Care Yes No Radiation Treatment Yes No Respitory Disease Yes No Rheumatic Fever Yes No Scarlet Fever Yes No Shortness of Breath Yes No Sinus Infection Yes No Skin Rash Yes No Stroke Yes No Swelling of Feet or Ankles Yes No Thyroid Problems Yes No Tobacco Habit Yes No Tonsillitis Yes No Tuberculosis Yes No Ulcer Yes No Venereal Disease Yes No Vitamin B12 Deficiency Yes No Are antibiotics necessary prior to treatment?* Yes No Signed ConsentI understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient's medical status. I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate treatment on the above-named patient. I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.HIPAA Patient ConsentI understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (a.k.a HIPAA or the Healthcare Privacy Act). I understand that by signing this consent, I authorize This Office to use and/ or disclose my protected healthcare information to carry out the following: • Treatment which includes direct and/ or indirect treatment by my other healthcare providers involved in my treatment. • Obtaining payment from third party payers, i.e. my dental and/or medical insurance company/companies. • The day to day healthcare operations of your dental practice. I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses of disclosures of my protected health information, and my rights under HIPAA. I understand that your reserve the right to change the terms of this notice from time to time and that I may request the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are not required to agree to use these requested restrictions. However, if you do not agree, you are bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent will not be affected.Financial PolicyFinancial Policy I understand that I am financially responsible for all charges whether or not I have insurance. If I have insurance, I authorize my insurance company to pay the dentist all insurance benefits rendered. I authorize the use of this electronic signature on all insurance submissions. I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.* I acknowledge that I have reviewed ALL questions on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes.* 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% per month on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied. This includes payments that are charged back.* I understand that any fee estimate for this dental care can only be extended for a period of six 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. 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. I also authorize to submit this form online.Typed Name/Signature(Required) Relationship to Patient(Required) Date(Required) MM slash DD slash YYYY CAPTCHA
