New Patient Packet

Name*

First NameMiddle NameLast Name

Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Please take a selfie of patient for patient chart.

Preferred Phone Number*

Area CodePhone Number

Do you mind receiving text messages?*

Is this a Cell phone number?*

Other phone number

Area CodePhone Number

Email

example@example.com

Social Security Number

Date of Birth*

Date

Sex*

Please upload patients Identification (Drivers License or Passport). If patient is under 18 please take photo of parent or guardians Identification.

Identification*

Browse Files

Emergency Contact*

First NameLast Name

Phone Number*

Area CodePhone Number

Relation

Mother

Is patient the responsible party?*

If patient is not the responsible party please fill out the remained of this section.

Name

First NameLast Name

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Date of Birth

Date

Responsible party identification

Browse Files

Driver License etc.

Sex:

Responsible party signature*

Date*

Date

Name

Smith on Vista

Phone Number

Area CodePhone Number

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Is subscriber the same as patient?

Subscriber information

Name

First NameMiddle NameLast Name

Subscriber Social Security Number

Date of birth

Date

Employer Name

Insurance Company

Insurance Phone number

Area CodePhone Number

Subscriber ID/Policy Number

Group/Contract Number

Patient Relationship to Subscriber

Insurance Card

Browse Files

Photo of insurance card

Name

First NameMiddle NameLast Name

Date of Birth

Date

Subscriber Social Security Number

Employer Name

Insurance Company

Insurance Phone Number

Area CodePhone Number

Subscriber IS/Policy Number

Group/Contract Number

Patient Relationship to Subsciber

Welcome! Please complete both sides of this dental/medical history form so that we may provide you with the best possible dental care.

All information is completely confidential.

How happy are you with your smile? Rate 1-10 (1 being not at all and 10 being very happy*

What is the reason for your visit today?*

Date of Last Dental Visit?

Last Dental Cleaning

Last Full Mouth X-rays

What was done at your last dental visit?

Previous Dentist’s Name

First NameLast Name

Previous Dentist’s Phone

Area CodePhone Number

Previous Dentist’s Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

How often do you have dental examinations?

How often do you brush your teeth?

How often do you floss?

What other dental aids do you use (Interplak, toothpick, etc.)?

Do you have any dental problems now?

If yes, please describe:

Have you ever had any complications with Novocaine or Local anesthetic? Explain what happened:

Are any of your teeth sensitive to

Hot or cold?

Sweets?

Biting or chewing?

Have you noticed any mouth odors or bad taste

Do you frequently get cold sores, blisters or any other oral lesions?

Do your gums bleed or hurt?

Have your parents experienced gum disease or tooth loss

Have you noticed any loose teeth or change in your bite

Does food tend to become caught in or between your teeth?

If yes, where?

Do you:

Clench or grind your teeth while awake or asleep?

Bite your lips or cheeks regularly?

Hold foreign objects with your teeth (pencils, pipe, pins, nails, fingernails)?

Mouth breathe while awake or asleep?

Have tired jaws, especially in the morning

Snore or have any other sleeping disorders

Smoke/chew tobacco or use other tobacco products?

Currently wear dentures

Have you ever had:

Orthodontic treatment?

Oral surgery

Periodontal treatment?

Your teeth ground or the bite adjusted

A bite plate or mouth guard

A serious injury to the mouth or head

If yes, please describe, including cause:

Have you experienced:

Clicking or popping of the jaw

Pain (joint, ear, side of face)

Difficulty in opening or closing the mouth

Difficulty in chewing on either side of the mouth

Headaches, neck aches or shoulder aches?

Sore muscles (neck, shoulders)

Are you satisfied with your teeth’s appearance

Would you like to keep all of your teeth all of your life

Do you feel nervous about having dental treatment

If so, what is your biggest concern

Have you ever had an upsetting dental experience

If yes, please describe

Have you ever been told to take a pre-medication prior to dental treatment?

Is there anything else about having dental treatment that you would like us to know?

If yes, please describe

Physician's Name

First NameLast Name

Phone Number

Area CodePhone Number

Have you had any medical care in the past two years?

Have you taken any medication or drugs during the past two years.**

Are you currently taking any medication, drugs, pills or herbal remedies, including regular dosage of aspirin?**

Have you ever taken prescription medication for weight loss (diet pill)?*

Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva, or other similar drugs?**

If yes, did you take any of the Following? (Check if yes)

Are you aware of having an allergic (or adverse) reaction to any substance or medication?**

If yes please specify

Have you been a patient in the hospital during the past five years?**

Check the conditions that apply to you:**

if yes to any of the above (diet pills area) did you have a medical exam for heart issues?

Current Medication List:*

Medication Patient is allergic to:**

Do you use or do you have history of using tobacco?**

Are you currently pregnant?

Do you use birth control prescriptions?

I understand the above information in necessary to provide me with dental care in a safe efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who mmay release such information to you. I will notify the doctor of any change in my health or medication.

Patient or Guardian Signature*

Date*

Date

Guardian Name*

First NameLast Name

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.

I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submission.

I acknowledge that I understand and have read the above conditions and payment stipulations and agree to their content.

Signature*

Date*

Date

(if patients is a minor or disabled the parent, guardian or attory-in-fact must sign and complete the responsilbe party section)

Consent to obtain patient medication history

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 insurers (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*

Date

I.V. Sedation Notification

Patients that require I.V. sedation will need to bill their own insurance companies for payment and they will be procedures prior to having the treatment done. Due to the inability to see other patients at the time that an I.V. Sedation is being performed, the amount of the treatment time @ $75.00 per every ½ Hour will be non-refundable in the event that you do not show for your scheduled appointment. A 48 Hour notice is required for all cancelled appointments. 20% of our usual fees will be added to each of the procedures even on PPO plans with insurance companies that we are currently contracted with and it will be solely the patient’s responsibility to pay this additional fee. This amount is non-refundable with patients insurance companies

Signature*

Date*

Date

(if patients is a minor or disabled the parent, guardian or attory-in-fact must sign and complete the responsilbe party section)

We strive to render excellent dental care to you and the rest of our patients. In an attempt to be consistent with this, we have an Appointment Cancellation Policy that allows us to schedule appointments for all patients. When an appointment is scheduled, that time has been set aside for you and when it is missed, that time cannot be used to treat another patient.
Our policy is as follows: We require that you give our office 48 hours’ notice in the event that you need to reschedule your appointment. This allows for other patients to be scheduled into that appointment. If you miss an appointment without contacting our office within the required time, this is considered a missed appointment. A No Show fee of $75.00 per hour will be charged to you; this fee cannot be billed to your insurance company and will be your direct responsibility. No future appointments can be scheduled nor can records be transferred without the payment paid in full of this fee.
Additionally, if a patient is more than 20 minutes late without prior notice for a scheduled appointment, we will consider this a missed appointment and the $50.00 cancellation fee will be charged.
If you have any questions regarding this policy, please let our staff know and we will be glad to clarify any questions you have. We thank you for your patronage.
I have read and understand the Appointment Cancellation Policy of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to-time by the practice.

I,*

Your full Name

have received a copy of Ramin Homanfar D.D.S. Appointment Cancellation Policy.

Signature*

Date*

Date

(if patients is a minor or disabled the parent, guardian or attory-in-fact must sign and complete the responsilbe party section)

Consent For Services | Finacial Agreement

All emergency dental services or any dental services without previous financial arrangements must be paid in cash at the time services are performed.

I agree to pay a cancellation fee of $75.00 per every 1/2 hour of the scheduled appointment time that was set aside if I cancel my appointment with the office or service without giving a 24 hour notice. This applies if I do not show for this appointment time and did not give the 24-hour notice.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and he/she is solely responsible for payment of all dental services. This office will help prepare the patient’s insurance forms or assist in making collections from insurance companies, financial intuitions & other forms of services, and we will credit any such collections to the patient’s account. However, the dental office cannot render services on the assumption that our charges will be paid by the insurance company.

A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previous written financial arrangements are made.

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient’s examination.

In consideration for the professional services rendered to me or for the guardianship for the patient/parental rights, or at my request, by the doctor, I agree therefore the reasonable value of said services to said doctor or his assignee at the time that said services are rendered, or within five days of billing, if credit shall be extended. I further agree that the reasonable value of said services shall be billed unless objected to, me by me, in writing, within the time for payment thereof.

I further agree that the waiver of any breach of any time or condition hereunder shall not contain a waiver or any further term or condition, and I agree to pay all cost, and reasonable attorney fees and collection agency fees if a suit were instituted hereunder.

I grant my permission for you or an assignee, to telephone me at home, or at work, or on my cell phone to discuss matters related to this form.

I HAVE READ THE ABOVE TERMS & CONDITIONS OF TREATMENT AND PAYMENT AND AGREE TO THEIR CONSENT

Signature*

Date*

Date

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

By signing below, I acknowledge that I have the opportunity to receive a copy of [Ramin Homanfar DDS] Notice of Privacy Practices. I have had an opportunity to ask questions about the use and disclosure of my health information, and other concerns regarding my health information.

Signature*

Date*

Date

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

Patient Packet

Patient Information

Responsible Party

Preferred Pharmacy

Primary Dental Insurance

Secondary Insurance

Dental History

Medical History

Women Patients

Patient Signatures

Appointment Cancellation Policy

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES