Phassfamilydentistry.com

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1 Patient Information
2 Dental Insurance
Who is responsible for this account? __________________________ Date ___________________________________________________ Relationship to Patient _____________________________________ SS/HIC/Patient ID # _____________________________________________ Insurance Co. ____________________________________________ Patient Name ____________________________________________ Group # ________________________________________________ _______________________________________________________ Is patient covered by additional insurance? □ Yes □ No Subscriber’s Name ________________________________________ Address ________________________________________________ Birthdate _____________________ SS# _____________________ City _____________________________________________________ Relationship to Patient _____________________________________ State ________________________ Zip ______________________ Insurance Co. ____________________________________________ E-mail ______________________________________________________________________________________________________________ Group # ________________________________________________ Sex □ M □ F Birthdate _______________________Age ________ ASSIGNMENT AND RELEASE
I certify that I, and/or my dependent(s), have insurance coverage with _____________________________________________ and assign directly to Occupation _______________________________________________ Dr.___________________________________________ all insurance benefits, if Patient Employer/School ____________________________________ any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize Employer/School Address __________________________________ the use of my signature on all insurance submissions.
_______________________________________________________ The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for Employer/School Phone (_____) _____________________________ the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current Spouse’s Name _____________________________________________ treatment plan is completed or one year from the date signed below.
Birthdate ________________________________________________ Signature of Patient, Parent, Guardian or Personal Representative SS# _____________________________________________________ Please print name of Patient, Parent, Guardian or Personal Representative Spouse’s Employer _________________________________________ Whom may we thank for referring you? ________________________ 3 Phone Numbers
Home (______) _______________________ Work (______) ___________________ Ext ______ Alt. Phone (______) _________________ Spouse’s Work (______) _______________________________________ Best time and place to reach you _____________________________ IN CASE OF EMERGENCY, CONTACT (Specify someone who does not live in your household.)
Name ______________________________________________________ Relationship _____________________________________________ Home Phone (______) ________________________________________ Work Phone (______) _____________________________________ 4 Dental History
Reason for today’s visit __________________ Cigarette, pipe, or cigar smoking □ Yes □ No Date of last dental visit __________________ Date of last dental X-rays ________________ Food col ection between the teeth □ Yes □ No Place a mark on “yes” or “no” to indicate if you Sores or growths in your mouth □ Yes □ No How often do you floss? _________________ – O V E R –
#21774 – Medical Arts Press 1-800-328-2179 5 Health History
Physician’s Name_________________________________________________________ Date of last visit ________________________________ Have you ever used a bisphosphonate medication? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva. □ Yes □ No Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). □ Yes □ No Place a mark on “yes” or “no” to indicate if you have had any of the following: AIDS/HIV Women:
Are you pregnant?
Due date_______ ___________________________ Medications
Allergies
List any medications you are currently taking and the correlating diagnosis: ________________________________________________________ ________________________________________________________ ________________________________________________________ Pharmacy Name _________________________________________ Phone (______) __________________________________________ 6 Updates (To be filled in at future appointments)
Has there been any change in your health since your last dental appointment? □ Yes □ No For what conditions? _____________________________________________________________________________________________________ Are you taking any new medications?______________ If so, what? ______________________________________________________________ Patient’s Signature _________________________________________________________________ Date ______________________________ Doctor’s Signature _________________________________________________________________ Date ______________________________ Has there been any change in your health since your last dental appointment? □ Yes □ No For what conditions? _____________________________________________________________________________________________________ Are you taking any new medications?______________ If so, what? ______________________________________________________________ Patient’s Signature _________________________________________________________________ Date ______________________________ Doctor’s Signature _________________________________________________________________ Date ______________________________ Patient Record of Disclosures
In general, the HIPAA privacy rule gives individual's the right to request a restriction of uses and disclosures of their protected health information. The individual is also provided the right to request confidential communications or that a communication of their protected health information be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home. I wish to be contacted in the following manner (check all that apply): Home Telephone
___ Ok to leave message with detailed information ___ Leave message with call back number only Work Telephone
___ Ok to leave message with detailed information ___ Leave message with call back number only Written Communication
___ Ok to mail to my provided home address ___ Ok to mail to my provided work/office address _________________________________________ Print _________________________________________ Sign

Source: http://www.phassfamilydentistry.com/New-Patient-Forms.pdf