Patient Registration

Patient Registration

Patient Information
Date

Month Day Year
Date
Patient Name *

First Name Middle Name Last Name
Patient Date of Birth *

Month Day Year
Date
Phone Number - Cell
Please enter a valid phone number.
Phone Number - Home
Please enter a valid phone number.
Email
example@example.com
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Sex

Male Female N/A
Whom may we thank for reffering you?
Emergency Contact
Contact Name
Relationship to Patient
Cell Phone
Home or Work Phone
Optional
Dental Insurance

If applicable
Insurance Company
Primary Subscriber
First Name, Last Name
Primary Subscriber Date of Birth
Date
Member ID/Social Security #
Group Number
ASSIGNMENT AND RELEASE

I certify that I, and/or my dependents, have coverage with Name of Insurance Company and assign directly to Dr. Daniel Hemmati all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by . I authorize the use of my signature on all submissions.

The above-named dentist may use my care information and may disclose such information to the above-named insurance company(ies) and their agents for the purpose of obtaining for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current reatment plan is completed or one year from the date signed below.
Signature (Patient, Guardian, or Responisble Party)

Clear
Date
Dental History
Date of Last Dental Visit
Date of Last Dental X-Rays
Bad Breath

Yes No
Bleeding Gums

Yes No
Blisters (Mouth or Lips)

Yes No
Chew on one side of mouth

Yes No
Cigarette, pipe, or cigar smoking

Yes No
Clicking or popping jaw

Yes No
Dry mouth

Yes No
Food collection between the teeth

Yes No
Grinding teeth

Yes No
Gums swollen or tender

Yes No
Jaw pain or tiredness

Yes No
Lip or cheek biting

Yes No
Loose teeth or broken fillings

Yes No
Pain around ear

Yes No
Periodontal treatment

Yes No
Sensitivity to cold

Yes No
Sensitivity to heat

Yes No
Sensitivity to sweets

Yes No
Sensitivity when biting

Yes No
Sores or growths in mouth

Yes No
How often do you floss?
How often do you brush?
Medical History
Physician's Name
Date of Last Visit
Please check yes or no to indicate if you have any of the following:
AIDS/HIV

Yes No
Hemophilia

Yes No
Alzheimer's

Yes No
Hepatitis A

Yes No
Anaphylaxis

Yes No
Hepatitis B or C

Yes No
Anemia

Yes No
Herpes

Yes No
Angina

Yes No
High Blood Pressure

Yes No
Arthritis / Gout

Yes No
High Cholesterol

Yes No
Artficial Heart Valve

Yes No
Hives or Rash

Yes No
Artificial Joint

Yes No
Hypoglycemia

Yes No
Asthma

Yes No
Irregular Heartbeat

Yes No
Blood Disease

Yes No
Kidney Problems

Yes No
Blood Transfusion

Yes No
Leukemia

Yes No
Breathing Problems

Yes No
Liver Disease

Yes No
Bruise Easily

Yes No
Low Blood Pressure

Yes No
Cancer / Chemotherapy

Yes No
Lung Disease

Yes No
Chest Pains

Yes No
Mitral Valve Prolapse

Yes No
Cold Sore/ Fever Blisters

Yes No
Osteoporosis

Yes No
Congenital Heart Disorder

Yes No
Pain In Jaw Joints

Yes No
Convulsions

Yes No
Parathyroid Disease

Yes No
Cortisone Medication

Yes No
Psychiatric Care

Yes No
Diabetes

Yes No
Radiation Treatment

Yes No
Chemical Dependency

Yes No
Recent Weight Loss

Yes No
Emphysema

Yes No
Renal Dyalisis

Yes No
Epilepsy or Seizures

Yes No
Rheumatism

Yes No
Excessive Bleeding

Yes No
Scarlet Fever

Yes No
Excessive Thirst

Yes No
Shingles

Yes No
Fainting Spells / Dizziness

Yes No
Sickle Cell Disease

Yes No
Frequent Cough

Yes No
Sinus Trouble

Yes No
Frequent Headaches

Yes No
Spina Bifida

Yes No
Genital Herpes

Yes No
Stomach/Intestinal Disease

Yes No
Glaucoma

Yes No
Stroke

Yes No
Hay Fever

Yes No
Swelling of Limbs

Yes No
Heart Attack

Yes No
Thyroid Disease

Yes No
Heart Murmur

Yes No
Tonsilitis

Yes No
Heart Pacemaker

Yes No
Tuberculosis

Yes No
Tuberculosis

Yes No
Tumors or Growths

Yes No
Ulcers

Yes No
Venereal Disease

Yes No
Jaundice

Yes No
Any conditions not listed?
Medications
List any medications you are currently taking
Allergies

Aspirin Barbiturates (Sleeping Pills) Codeine Iodine Local Anesthetic Penicillin Sulfa Other
Notice of Privacy Practices

This notice describes how health information about you may be disclosed and how you can obtain access to this information. Please review it carefully. The privacy of your information is important to us.
OUR LEGAL DUTY

We are required by applicable federal and state law to maitain the privacy of your health information. We must follow the privacy practices that are described in this notice while it is in effect. This Notice takes effect on the date signed below, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this notice at any time, time, provided such changes are permitted by applicable law. We reserve the right to make the chnages in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health infomation we created or rcieved before changes were made. Before we make a significant change in our privacy policies, we will change this notice and make the new notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.
USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment and healthcare operations. For example:

Treatment: We may use and disclose your health information to obtain payment for services we provide you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assesment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance conducting training programs, accreditation, certifications, licensing, or credentialing activities.

Your Authorization: In addition to our use of health information for treatment, payment and healthcare operations, you may give us written authorizationto use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use mor disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this notice.
By signing below, I acknowledge I have reviewed and accept the terms of this Notice of Privacy Practices listed above.
Signature

Clear
Date
Should be Empty:

Patient Registration

Emergency Contact

Dental Insurance

Dental History

Medical History

Notice of Privacy Practices