New Patient Forms Packet

Patient Registration Form
Patient's Legal Name*

First NameMiddle NameLast Name
Date of Birth*

MonthDayYear
Date
Sex*

MaleFemale
Social Security Number*
Prefer to Be Called
Home Phone #
Cell Phone #
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email*
example@example.com
Marital Status*

SingleMarriedWidowedDivorcedUnder Age 18
Patient/Guardian's Employer*
Occupation
Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Work Phone Number
Spouse's Name

First NameMiddle NameLast Name
Spouse's Employer
Spouse's Occupation
Spouse's Work Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse's Work Phone Number
Other Family Members That Are Patients Here
Who Can We Thank For Referring You To Our Office?
Emergency Contact Information

Person We May Contact in Case of An Emergency (Other Than Your Family Home)
Emergency Contact Name*

First NameLast Name
Relationship to Patient*
Home Phone Number

Area CodePhone Number
Work Phone Number

Area CodePhone Number
Cell Phone Number

Area CodePhone Number
Request for Confidential Communication

As My Dental Care Provider, You May Do The Following With My Permission*

	Yes	No
Contact Me At Home
Contact Me Via Cell Phone
Contact Me At Work
Contact Me Via Email
Leave Messages On My Home Voicemail/Answering Machine
Leave Messages On My Cell Phone Voicemail
Leave Messages On My Work Voicemail/Answering Machine

Insurance and Financial Information
Insurance Coverage*

YesNo
Insurance Company Name*
Insurance Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Insurance Phone Number*
Subscriber's Name*

First NameLast Name
Patient's Relationship to Subscriber*

SelfSpouseDependent
Subscriber's Birthday*

MonthDayYear
Date
Subscriber's SSN/ID#*
Group/Program Number*
Employer (If Different from Above)
Employer's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Release Information
You May Discuss My Healthcare With:
Health Care Providers*

YesNo
Insurance Companies*

YesNo
Others (Enter Below)
Confirmations
Do You Prefer a Confirmation Call?*

No, It is unnecessaryYes, It is a helpful reminder
Assignment & Release
I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due to and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy.

I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor in scientific papers, demonstrations, and/or presentations.

I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved.
Signature*

Clear
Date*

MonthDayYear
Date

Consent of Treatment
1*
2.

Upon such diagnosis, I authorize Doctor Oshins to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
3.

I agree to the use of anesthetics, sedatives, and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks, I understand that I can ask for a complete recital of any possible complications.
4.

I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1/2% (18% APR) may be added to my account. I also agree to pay any legal interest on the balance due together with any collection costs and attorney fees incurred in the attempt of collection of this account.
Patient's Signature*

Clear
Date*

MonthDayYear
Date
Parent/ Responsible Party's Signature

Clear
Relationship to Patient

HIPPA Consent Form
HIPAA – Notice of Privacy Practice

HIPAA is a federal law developed to provide a standard for the protection of your health information. The purpose of the Notice of Privacy Practice is to explain how Oshins of Smiles may use or disclose your health care information. The Notice also explains the rights that you are guaranteed under HIPAA regulations. Though Oshins of Smiles has always taken great care to protect the integrity and confidentiality of your health care information, we are now required by the HIPAA Privacy Rule to distribute this notice to you and obtain acknowledgment that you have received the Notice. Signing below indicates that you have received the Notice of Privacy Practice.

I hereby acknowledge that I received a copy of Oshins of Smiles Notice of Privacy Practices.
Initials of Patient/Guardian*

Clear
Permission to Share Medical Information

My Medical Information may be obtained and exchanged verbally to:
Name
Relationship
Initials of Patient/Guardian*

Clear
Permission to Bill Your Insurance

All professional services rendered are charged to the patient. Necessary forms will be completed by Oshins of Smiles to help expedite insurance carrier payments. However, the patient is responsible for all fees, regardless of insurance coverage.

I understand my signature authorizes releasing of the information to the insurer or agency given to Oshins of Smiles for participating health insurance plans.
Signature of Patient/Guardian*

Clear
Date*

MonthDayYear
Date

Appointment Policy
Welcome to Oshins of Smiles! We appreciate your decision to come to us for your dental needs.

As a patient, it is important that you understand our commitment to providing timely and quality service to all of our patients. An important aspect of this service is the commitment of each patient to honor their appointment by both showing up in a timely manner, as well as giving proper notice if they are unable to keep their scheduled appointment. We ask that, whenever possible, you provide us with 48 business hours (Monday through Thursday) notice for appointments that you cannot keep. Missed appointments increase the cost of healthcare for everyone. Unless an emergency, cancellations or appointment changes made with less than 48-hours notice will incur a fee.

I have read, understand the appointment policy. Please initial below:
Patient Initials*

Clear
Date*

MonthDayYear
Date

Oshins of Smiles Financial Policy
Our office is committed to providing you with the best possible dental care. If you have dental insurance, we are happy to you help you receive your maximum allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our payment policy. We will gladly answer any questions relating to your insurance. Your insurance is a contract between you, your employer, and your insurance company. Not all services are covered benefits in all contracts. There are some procedures insurance companies do not cover. Insurance companies rarely reimburse the full amount of restorations, or major procedures. Generally they pay 50% to 80% of the fee.

We are happy to file all insurance claims for you. Our filing the claim on your behalf does not guarantee payment nor does a pre-determination of benefits represent a guarantee of payment. Our office will estimate what your portion will be based on information we have available to us, any balance is expected in full at time of service. Some insurance companies pay the patient directly and in turn we ask that you pay the entire amount at time of service. Any balance not paid by the insurance company is solely your responsibility.

We must emphasize that as dental care providers, our relationship is with you and not your insurance company. While the filing of insurance claims for dental charges is a courtesy we extend to our patients, all charges are your responsibility from the date the services are rendered.

Any account with an outstanding balance that has not been paid in full within 90 days will be considered delinquent and will be referred to an outside agency for collection. If an account is sent to this agency, the patient or patient's guarantor will bear the responsibility of any fees involved in collection on that account.

If you have any questions about the above information, please don't hesitate to ask us.
Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

	Yes	No
Aspirin, Ibuprofen, Acetaminophen, Codeine
Penicillin
Erythromycin
Tetracycline
Sulfa
Local Anesthetic
Fluoride
Chlorhexidine (CHX)
Metals (nickle, gold, silver, other metals)
Latex
Nuts
Fruit

	Yes	No
Hospitalization for illness or injury
Heart problems or cardiac stent within the last 6 months
History of infective endocarditis
Artificial heart valve, repaired heart defect (PFO)
Pacemaker or implantable defibrillator
Orthopedic implant (joint replacement)
Rheumatic or scarlet fever
High or low blood pressure
A stroke (taking blood thinners)
Anemia or other blood disorder
Prolonged bleeding due to a slight cut (INR >3.5)
Pneumonia, emphysema, shortness of breath, sarcoidosis
Chronic ear infections, tuberculosis, measles, chicken pox
Asthma
Breathing or sleep problems (e.g. sleep apnea, snoring, sinus)
Kidney disease
Liver disease
Jaundice
Thyroid, parathyroid disease, or calcium deficiency
Hormone deficiency
High cholesterol or taking statin drugs
Diabetes
Stomach or duodenal ulcer
Digestive or eating disorders
Osteoporosis/osteopenia (e.g. taking bisphosphonates)
Arthritis
Autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)
Glaucoma
Contact lenses
Head and neck injuries
Epilepsy, convulsions (seizures)
Neurologic disorders (ADD/ADHD, prion disease)
Viral infections and cold sores
Any lumps or swelling in the mouth
Hives, skin rash, hay fever
STI/STD/HPV
Hepatitis A
Hepatitis B
Hepatitis C
Hepatitis D
Hepatitis E
HIV/AIDS
Tumor, abnormal growth
Radiation therapy
Chemotherapy, immunosuppressive medication
Emotional difficulties
Psychiatric Treatment
Antidepressant Medication
Alcohol/ recreational drug use

	Yes	No
Presently being treated for any other illness
Aware of a change in your health in the last 24 hours (e.g. fever, chills, new cough, or diarrhea)
Taking medication for weight management
Taking dietary supplements
Often exhausted or fatigued
Experiencing frequent headaches
A smoker, smoked previously or use smokeless tobacco
Consider a touchy/sensitive person
Often unhappy or depressed
Taking birth control pills
Currently pregnant
Diagnosed with a prostate disorder

	Drug	Purpose
1.
2.
3.
4.
5.
6.
7.
8.

	Yes	No
Are you fearful of dental treatment?
Have you had an unfavorable dental experience?
Have you ever had complications from past dental treatment?
Have you ever had trouble getting numb or had any reactions to local anesthetic?
Did you ever have braces, orthodontic treatment, or had your bite adjusted?
Have you had any teeth removed, missing teeth that never developed, or lost teeth due to injury or facial trauma?

Patient Registration Form

Emergency Contact Information

Request for Confidential Communication

Insurance and Financial Information

Release Information

Confirmations

Assignment & Release

Consent of Treatment

HIPPA Consent Form

Medical History

Medical History

Dental History

Please Answer Yes or No to the Following:

Sleep Apnea Patient Questionnaire

STOP-BANG Patient Questionnaire

Epworth Sleepiness Scale

Appointment Policy

Oshins of Smiles Financial Policy

	Yes	No
Do your gums bleed or are they painful when brushing or flossing?
Have you ever been treated for gums disease or been told you have lost bone around your teeth?
Have you ever noticed an unpleasant taste or odor in your mouth?
Is there anyone with a history of periodontal disease in your family?
Have you ever experienced gum recession?
Have you ever had any teeth become loose on their own (without injury), or do you have difficulty eating an apple?
Have you experienced a burning or painful sensation in your mouth not related to your teeth?

	Yes	No
Have you had any cavities within the past 3 years?
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing food?
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth?
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth?
Do you have grooves or notches on your teeth near the gum line?
Have you ever broken teeth, chipped teeth, or had toothache or cracked filling?
Do you frequently get food caught between any teeth?

	Yes	No
Do you have problems with your jaw joint? (Pain, sounds, limited opening, locking, popping)
Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods?
In the past 5 years, have your teeth changed (becomes shorter, thinner, or worn) or has your bite changed?
Are your teeth becoming more crooked, crowded, or overlapping?
Are your teeth developing spaces or becoming more loose?
Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?
Do you place your tongue between your teeth or close your teeth against your tongue?
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits?
Do you clench or grind your teeth together in the daytime or make them sore?
Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth?
Do you wear or have you ever worn a bite appliance?

	Yes	No
Is there anything about the appearance of your teeth that you would like to change (shape, color, size)?
Have you ever whitened (bleached) your teeth?
Have you felt uncomfortable or self conscious about the appearance of your teeth?
Have you been disappointed with the appearance of the previous dental work?

	Yes	No
SNORING - Do you snore loudly (louder than talking or loud enough to be heard through closed doors)?
TIREDNESS/FATIGUE - Do you often feel tired, fatigued, or sleepy during the daytime, even after a “good” night’s sleep?
OBSERVED APNEA - Has anyone ever observed you to stop breathing during your sleep?
PRESSURE - Do you have or are you being treated for high blood pressure?
BODY MASS INDEX - More then 35? (BMI Formula: weight (lb) / Height (in)2 x 703)
AGE - Are you older than 50 years?
NECK SIZE - Does your neck measure more than 15 ¾ inches (40 cm) around?
GENDER - Are you male?

	0	1	2	3
Sitting and Reading
Watching Television
Sitting inactively in a public place (for example a theater or meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch (when you've had no alcohol)
In a car, when stopped in traffic