New Patient Packet

Patient Packet
Patient Information
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?*

YesNo
Is this a Cell phone number?*

YesNo
Other phone number

Area CodePhone Number
Email
example@example.com
Social Security Number
Date of Birth*

MonthDayYear
Date
Sex*

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

Browse Files

Cancelof
Emergency Contact*

First NameLast Name
Phone Number*

Area CodePhone Number
Relation
Mother
Responsible Party
Is patient the responsible party?*

YesNo
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

MonthDayYear
Date
Responsible party identification

Browse Files
Driver License etc. Cancelof
Sex:

FemaleMaleUnspecified
Responsible party signature*

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Date*

MonthDayYear
Date
Preferred Pharmacy
Name
Smith on Vista
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Primary Dental Insurance
Is subscriber the same as patient?

YesNo
Subscriber information
Name

First NameMiddle NameLast Name
Subscriber Social Security Number
Date of birth

MonthDayYear
Date
Employer Name
Insurance Company
Insurance Phone number

Area CodePhone Number
Subscriber ID/Policy Number
Group/Contract Number
Patient Relationship to Subscriber

ChildDisabled DependentHusbandSelfWifeOther Dependent
Insurance Card

Browse Files
Photo of insurance card Cancelof
Secondary Insurance
Name

First NameMiddle NameLast Name
Date of Birth

MonthDayYear
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

ChildDisabled DependentHusbandSelfWifeOther Dependent
Dental History
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?

YesNo
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?

YesNo
Sweets?

YesNo
Biting or chewing?

YesNo
Have you noticed any mouth odors or bad taste

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

YesNo
Do your gums bleed or hurt?

YesNo
Have your parents experienced gum disease or tooth loss

YesNo
Have you noticed any loose teeth or change in your bite

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

YesNo
If yes, where?
Do you:
Clench or grind your teeth while awake or asleep?

YesNo
Bite your lips or cheeks regularly?

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

YesNo
Mouth breathe while awake or asleep?

YesNo
Have tired jaws, especially in the morning

YesNo
Snore or have any other sleeping disorders

YesNo
Smoke/chew tobacco or use other tobacco products?

YesNo
Currently wear dentures

YesNo
Have you ever had:
Orthodontic treatment?

YesNo
Oral surgery

YesNo
Periodontal treatment?

YesNo
Your teeth ground or the bite adjusted

YesNo
A bite plate or mouth guard

YesNo
A serious injury to the mouth or head

YesNo
If yes, please describe, including cause:
Have you experienced:
Clicking or popping of the jaw

YesNo
Pain (joint, ear, side of face)

YesNo
Difficulty in opening or closing the mouth

YesNo
Difficulty in chewing on either side of the mouth

YesNo
Headaches, neck aches or shoulder aches?

YesNo
Sore muscles (neck, shoulders)

YesNo
Are you satisfied with your teeth’s appearance

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

YesNo
Do you feel nervous about having dental treatment

YesNo
If so, what is your biggest concern
Have you ever had an upsetting dental experience

YesNo
If yes, please describe
Have you ever been told to take a pre-medication prior to dental treatment?

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

YesNo
If yes, please describe
Medical History
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.**

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

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

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

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

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

YesNo
If yes please specify
Have you been a patient in the hospital during the past five years?**

YesNo
Check the conditions that apply to you:**

Alcoholism/Drug addictionHeart (Disease, surgery, attack)Chest PainCongenital Heart DiseaseHeart MurmurHigh Blood PressureMitral Valve ProlapseArtificial Heart Valve/PacemakerRheumatic FeverArthritis/RheumatismCortisone MedicineSwollen anklesStrokeDiet (Special/Restricted)Artificial Joints (Hip, Knee, Etc.)Organ transplantAspirin Therapy/blood thinnerAnemiaKidney DiseaseUlcersThyroid ProblemsGlaucomaExcessive bleedingEmphysemaChronic CoughAsthmaHay Fever/Allergy/HivesLatex SensitivitySinus ProblemsRadiation TherapyChemotherapyTumors/CancerHepatitis A, B, CVenereal DiseaseAIDS/HIV PositiveCold Sores/Fever BlisterHemophiliaSickle Cell DiseaseBruise EasilyLiver Disease/Yellow JaundiceNeurological DisorderEpilepsy or SeizuresFainting or Dizzy SpellsNervous/AnxiousPsychiatric/Psychological careLung Disease/COPDDementiaAny other disease, condition, or problem not listedNone
if yes to any of the above (diet pills area) did you have a medical exam for heart issues?

YesNo
Current Medication List:*
Medication Patient is allergic to:**
Do you use or do you have history of using tobacco?**

YesNo
Women Patients
Are you currently pregnant?

YesNoType option 3
Do you use birth control prescriptions?

YesNo
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*

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Date*

MonthDayYear
Date
Guardian Name*

First NameLast Name
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.

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*

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Date*

MonthDayYear
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*

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Date*

MonthDayYear
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 24 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*

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Date*

MonthDayYear
Date
(if patients is a minor or disabled the parent, guardian or attory-in-fact must sign and complete the responsilbe party section)
Appointment Cancellation Policy
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 24 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*

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Date*

MonthDayYear
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*

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Date*

MonthDayYear
Date
(If patient is a minor or disabled the Parent, Guardian or Attorney-in-Fact must sign and complete the Responsible Party section)
ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES
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*

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Date*

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

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