Access Dental Care New Patient Registration Dental Hygiene

New Patient Registration

Access Dental Care
Today's Date

Month Day Year
Email
example@example.com
Name *

First Name Last Name
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Home Phone Number *

Area Code Phone Number
Business/Cell Phone Number

Area Code Phone Number
Weight *
Height *
Date of Birth *

Month Day Year
Occupation *
Sex *

Male Female Other
SS# or Patient ID
If you are completing this form for another person, what is your relationship to that person?
Your Name

First Name Last Name
Relationship to Patient
Emergency Contact Info
Name *

First Name Last Name
Home Phone Number *

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Relationship to Patient *
Medical Information
Current Dentist Name

First Name Last Name
Current Dentist Phone Number

Area Code Phone Number
Date of last X-Rays
Medical History
Do you have any of the following diseases or problems? *

Active tuberculosis? Persistent cough greater than 3 weeks? Cough that produces blood? Been exposed to anyone with tuberculosis? Don't Know
Are you now under the care of a physician? *

Yes No Don't Know
Physician Name *

First Name Last Name
Physician Phone Number *

Area Code Phone Number
Physician Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Are you in good health? *

Yes No Don't Know
Have there been any changes in your health in the past year? *

Yes No Don't Know
Please explain these changes below: *
Date of last physical exam? *
Have you been hospitalized in the past 5 years? *

Yes No Don't Know
What was the illness or problem? *
Are you taking or have you recently taken any prescription or over the counter medicine(s)? *

Yes No Don't Know
Please list all prescription and over the counter medications including name, dosage, purpose and time of day taken. This includes vitamins, natural, or herbal preparations and/or dietary supplements. *
Do you wear contact lenses? *

Yes No Don't Know
Have you had an orthopedic total joint (hip, knee, elbow, finger, etc) replacement? *

Yes No Don't Know
Please include date, type of replacement and any complications below: *
Are you taking or planning to take an antiresorptive agent (such as Fosamax, Actonel, Boniva, Reclast, and Prolia)? *

Yes No Don't Know
Since 2001, have you or will you be treated with an antiresorptive agent (Aredia, Zometa, XGEVA)? *

Yes No Don't Know
For which condition? *

Bone pain Paget’s disease Multiple myeloma Metastatic cancer
What type, dosage and when was it taken? *
Do you use controlled substances (drugs)? *

Yes No Don't Know
Do you use tobacco (smoking, snuff, chew, bidis)? *

Yes No Don't Know
How interested are you in stopping? *

Very Somewhat Not Interested
Do you drink alcohol? *

Yes No Don't Know
If yes, how many drinks in last 24 hours? How many per week? *
Please include what type, dosage and when was it taken? *

WOMEN ONLY Are you? *

	Yes	No	Don't Know
Pregnant?
Taking birth control pills or hormonal replacement?
Nursing?

Allergies. Are you allergic to or had a reaction to the following: *

	Yes	No	Don't Know
Local anesthetics
Aspirin
Penicillin or other antibiotiics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Metals
Latex (rubber)
Iodine
Hay feveer
Animals
Food
Other

If yes to any please specify type and reaction. *
Please indicate if you have or have had any of the following diseases or problems: *

Cardiovascular disease Congestive heart failure Low blood pressure Mitral valve prolapse Rheumatic heart disease Blood transfusion Arthritis Systemic lupus erythematous Emphysema Chest pain upon exertion Eating disorder GI reflux/ persistent heart burn Angina Heart attack High blood pressure Pacemaker Abnormal bleeding Hemophilia Autoimmune disease Asthma Sinus trouble Chronic pain Malnutrition Ulcers Arteriosclerosis Heart murmur Other congenital heart defect Rheumatic fever Anemia AIDS/HIV Rheumatoid arthritis Bronchitis Cancer/chemotherapy/radiation Diabetes 1 or 2 Gastrointestinal disease Thyroid problem Stroke Epilepsy Sleep disorder Recurrent infection Osteoporosis Severe or rapid weight loss Glaucoma Fainting spells or seizures Snoring Kidney problems/dialysis Persistent swollen glands in neck Sexually transmitted disease Damaged heart valves Hepatitis, jaundice or ulcers Neurological disorder Mental health disorder Night sweats Severe headaches/ migraines Excessive urination Herpes, cold sores, fever blisters
If yes to any, list dates, kinds, controlled or uncontrolled *
If yes to any of the following CHD conditions, antibioticprophylaxis is recommended. Consult physician. *

Artificial (prosthetic) valve Previous infective endocarditis Damaged valves in transplanted heart CHD; unrepaired cyanotic CHD CHD; repaired completely in last 6 months CHD; repaired with residual defects None of the above
Has a physician or dentist recommended that you take antibiotics prior to dental treatment? *

Yes No
Do you have any diseases or problems not listed above that you think I should know about? *

Yes No
If yes, what? *
Dental Information
Grind your teeth? *

Present Past Never
Bite your cheek? *

Present Past Never
Tongue thrust? *

Present Past Never
Mouth breather? *

Present Past Never
Bite nails? *

Present Past Never
Suck your thumb/finger? *

Present Past Never
Use a toothpick or stimulator? *

Present Past Never
Use chewing gum? *

Present Past Never
Eat candy? *

Present Past Never
Drink soft drinks? *

Present Past Never
How often do you brush? When? *
How often do you floss? When? *
Do you use mouthwash? What type? *
Other types of oral health instruments? *
Personal or family history of oral cancers? *

Yes No High risk
Are you currently experiencing pain in your mouth? *

Yes No
If yes, where at, what type and for how long? *
Do your gums bleed when you brush or floss? *

Yes No Don't Know
Is your mouth dry? *

Yes No Don't Know
Are your teeth sensitive to hot/cold *

Present Past Never
Are your teeth sensitive to biting or chewing? *

Present Past Never
Are your teeth sensitive to sweets? *

Present Past Never
Is your home water supply fluoridated? *

Present Past Never
Do you drink bottled or filtered water? *

Yes No Don't Know
Have you ever had orthodontic (braces) treatment? *

Present Past Never
Have you ever had orthodontic treatment? *

Present Past Never
Have you had a bite plate / guard? *

Present Past Never
Have you had periodontic treatment? *

Present Past Never
Do you have earaches or neck pain? *

Yes No Don't Know
Do you have clicking, popping or discomfort in the jaw? *

Yes No Don't Know
Do you have sores or ulcers in your mouth? *

Yes No Don't Know
Do you wear dentures or partials? *

Yes No Don't Know
Have you had oral surgery? *

Present Past Never
Have you had a serious injury to your mouth or head? *

Present Past Never
Have you had any problems associated with previous dental treatment? *

Yes No
How do you feel about your smile? *
What is your normal schedule for dental cleanings? (Ex. Every 6 mo) *
Date of last dental appointment? *
Any complications from dental treatment? *
Do you participate in sports? *

Scan Insurance & ID Cards

Patient Information
Patient ID:
Patient Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Scan Your Insurance Card
FRONT of Insurance Card

Take Photo

Cancel of
BACK of Insurance Card

Take Photo

Cancel of
Scan Your Driver's License
FRONT of Driver's License

Take Photo

Cancel of
BACK of Driver's License

Take Photo

Cancel of

Notice of Privacy Practices

Access Dental Care / appointments@accessdentalcareri.com / 1234 Mineral Spring Ave. North Providence, RI
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN OBTAIN ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

We respect our legal obligation to keep health information that identifies you private. We are obligated by law to give notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it.

TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS

The most common reason why we use or disclose your health information is for treatment, payment, and health care operations. Examples of how we disclose information for treatment purposes are: setting up an appointment for you; examining your teeth; prescribing medications and faxing them to be filled; referring you to another doctor or clinic for other health care or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we disclose your health information for payment purposes are: asking about your health or dental plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through collecting agency or attorney). "Health are operations"means those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning; and outside storage of our records.

We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we will ask you for special written permission.

USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION

In some limited situations, the law allows or requires us to use or disclose your information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such cases or disclosures are:
- when a state or federal law mandates that certain health information be reported for specific purpose;
- for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices;
- disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence;
- uses and disclosures for health oversight activities, such as for the licensing doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws;
- disclosures of judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies;
- disclosures of law enforcement purposes, such as to provide information about someone who is suspected to be victim of a crime, to provide information about a crime at our office; or to report a crime happened somewhere else;
- dislosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;
- uses or disclosures of health related research;
- uses or disclosures to prevent a serious threat to health or safety;
- uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activites; for military purposes; or for evaluation and health of members of the foreign service;
- disclosures of de-identified information;
- disclosures relating to worker's compensation programs;
- disclosures of a "limited data set" for research, public health operations for us and who commit to respect the privacy of your health information;
- specify other uses and disclosures affected by state law.
Unless you object, we will also share relevant information about your care with your family or friend who are helping you with your dental care.

APPOINTMENT REMINDERS

We may call or write to remind you of scheduled appointments, or that is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we may mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home.

OTHER USES AND DISCLOSURES

We will not make any other uses or disclosures of your health information unless you sign a written "authorization form." The content of an "authorization form" is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes you may initiate the process if it's your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use of disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing, Send them to the office contact person named at the beginning of this Notice.

YOUR RIGHTS REGARDING YOUR HEALTH INFORMATON

The law gives you many rights regarding your health information. You can:
- ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions you want. To ask for a restriction, send a written request to the office contact person at the address, fax, E mail shown at the beginning of this Notice.
- ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using E mail to your personal E mail address. We will accomodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
- ask us to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
- ask us to amend your health information if you think that is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can make a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have only 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
- get a list of the disclosures that we have made for your health information within the past six years (or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosure with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have 30 day extension of time if we notify you the extension in writing. If you want a list, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
- get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies. send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.
OUR NOTICE OF PRIVACY PRACTICES

By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we may generate in the future. If we change our Notice of Privay Practices, we will post the new notice in our office, have copies available in our office, and post it in our Website.

COMPLAINTS

If you think that we have not properly respected the privacy of your health information, you are free to complain to us the U.S. Department of Health and Human Resources, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.

FOR MORE INFORMATION

If you want more information about our privacy practices, please contact the office.
Acknowledgement of HIPAA
Name *

First Name Last Name
Today's Date *

Month Day Year
Date
Signature *

Clear

Access Dental Care Financial Agreement
Thank you for choosing Access Dental as your dental care provider. Dr. Manousos and Tabatabaie are committed to your treatment being successful. Please understand that payment of your bill is considered part of your treatment. The following is a statement of our financial policy which are required that your read and sign prior to any treatment.

INSURANCE: All charges you incur are your responsibility regardless of your insurance coverage. Your insurance policy is a contract between you, your employer, and the insurance company. Our office is not part of that contract. As a courtesy to you we will help you by sending your insurance claims. Co-payments collected may be based on estimates by Access Dental Care staff using the insurance information available at the time. Any underpayments will be due after claims process. Any overpayments may be used as credit toward future treatments, transferred to family members or refunded to you per your reference.

PAYMENTS: All payments or co-payments will be collected at the date of service. For multi-visit treatments, payment will be collected at the first appointment unless other arrangements have been made. For some larger procedures that require lengthier appointment times, we may ask that you pay in advance of the date of service in order to reserve the scheduled time.

Our office accepts cash, personal checks, Mastercards, Visa, Discover and American Express. We offer payment plans through third party financing.

In the event that a check is returned to our office by your financial institutions, you will be responsible for any returned check fees that are charged to our office.

Past due accounts may be turned over to a billing agency collection. In this case the patient will be responsible for payment of collection feees and court costs associated witht the monies due on the account.

APPOINTMENT CANCELLATIONS: We ask that you kindly give at least 48 hours notice of cancellations. If you know you are not going to be able to make an appointment, please call us as soon as possible. We understand that unavoidable circumstances arise and will work with you to find a solution. We may apply a missed appointment fee of $75. Multiple failed appointments may lead to termination of our relationship.

If you have any questions regarding our financial policy, please ask. We are committed to providing you with the most positive experience in dental care.

AUTHORIZATION

Access Dental Care, P.C., may use health care information and may disclose such information to my insurance company, and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.

I understand that I am financially responsible for all charges whether or not paid by my insurance. I authorize the use of my signature on all insurance submissions (if applicable)
Patient Name *

First Name Last Name
Date

Month Day Year
Date
Signature

Clear
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New Patient Registration

Emergency Contact Info

Medical Information

Medical History

Dental Information

Scan Insurance & ID Cards

Scan Your Insurance Card

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Omnibus Rule

HIPAA NOTICE OF PRIVACY PRACTICES

Name of Facility: Access Dental

Patient Acknowledgement Form

Notice of Privacy Practices

Acknowledgement of HIPAA

Access Dental Care Financial Agreement