Creating Beautiful Smiles New Patient Form

PATIENT REGISTRATION

Please complete the following confidential information
IF THIS APPOINTMENT IS FOR YOU START HERE
Date

MonthDayYear
Date
Name:*

First NameLast Name
Spouse:

First NameLast Name
Address:*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number:*
Please enter a valid phone number.
Cell Phone Number:
Please enter a valid phone number.
Select which preferred to Contact you:

Home PhoneCell PhoneText Message
Birthdate:*

MonthDayYear
Date
Age:
Gender:

MaleFemale
Marital Status:

SingleMarriedDivorcedWidowed
Social Security Number:
IF THIS APPOINTMENT IS FOR CHILD START HERE
Name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number:
Please enter a valid phone number.
Cell Phone Number:
Please enter a valid phone number.
Select which preferred to contact you:

Home PhoneCell PhoneText Message
Birthdate:

MonthDayYear
Date
Age:
Gender:

MaleFemale
School:
Grade:
Social Security Number:
IF YOUR CHILD'S LAST NAME AND/OR ADDRESS ARE NOT THE SAME AS YOURS. FILL IN THE TOP BOX ALSO.
DENTAL INSURANCE

PRIMARY CARRIER
Insurance Company:
Group Number:
Employee:
Date of Birth:

MonthDayYear
Date
Date Employed:

MonthDayYear
Date
Union or Local Number:
Employee Number:
Employee Social Security Number:
GETTING TO KNOW YOU
IS ANOTHER MEMBER OF YOUR FAMILY OR RELATIVE A PATIENT AT OUR OFFICE?
Name:

First NameLast Name
Relationship:
Referred to us by:
Person to Contact for Emergency:
Phone Number:
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Select which preferred to contact you:

Home PhoneCell PhoneText Message
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Closest Relative Not Living With You:
Phone Number:
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
ACCOUNT INFORMATION

PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT
Name:

First NameLast Name
Relationship to Patient:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
Please enter a valid phone number.
Cell Phone Number:
Please enter a valid phone number.
YOU
Name:

First NameLast Name
Occupation:
Employer:
Business Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number:
Please enter a valid phone number.
Home Phone Number:
Please enter a valid phone number.
Cell Phone Number:
Please enter a valid phone number.
YOUR SPOUSE
Name:

First NameLast Name
Occupation:
Employer:
Business Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Phone Number:
Please enter a valid phone number.
Home Phone Number:
Please enter a valid phone number.
Cell Phone Number:
Please enter a valid phone number.
CONSENT FOR TREATMENT
1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and any other diagnostic aids deemed appropriate by doctor to make diagnosis of ___________________ dental needs.
Name:
2. Upon such diagnosis, I authorize doctor 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. Lastly, I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payments is due at the time of service unless other arrangements have been made. In the event payments are not rendered by agreed upon dates, I understand that a 1 1/2% late charge (18% APR) may be added to my account.
Patient:
Date:

MonthDayYear
Date
Witness:
Parent or Responsible Party:
Relationship to Patient:
DENTAL HISTORY

Welcome! So that we may provide you with the best possible care please complete both medical/dental history form. All information is completely confidential.
Patient Name:

First NameLast Name
Patient Account Number:
Medical Alert
What is the reason for your visit today?
Date of Last Visit?

MonthDayYear
Date
Last Dental Cleaning?

MonthDayYear
Date
Last Full Mouth X-rays?

MonthDayYear
Date
What's was done at your last dental visit?
Previous Dentist's Name:
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number:
Please enter a valid phone number.
Cell Phone Number:
Please enter a valid phone number.
How often do you have dental examinations?
How often do you brush your teeth?
How often do you floss your teeth?
What other dental aids do you use? (interplak, toothpick, etc.)
Do you have any other dental problems now?

YesNo

Are any of your teeth sensitive to:

	Yes	No
Hot or cold?
Sweets?
Biting or chewing?
Have you noticed any mouth odors or bad tastes?
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 between your teeth?

If yes, where?

Do you?

	Yes	No
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 breath while awake or asleep?
Have tired jaws, especially in the morning?
Smoke/chew tobacco?

Have you ever had?

	Yes	No
Orthodontic treatment?
Oral surgery?
Hold foreign objects with your teeth? (Pencils, pipe, pins, nails, fingernails)
Periodontal treatment?
Your teeth ground or bite adjusted?
A bite plate or mouth guard?
A serious injury to the mouth or head?

If so, please describe including cause

Have you experienced?

	Yes	No
Clicking or popping of the jaw?
Pain? (Pint, ear, side of face)
Difficulty in chewing on either side of the mouth?
Headaches, neckaches, or shoulder aches?
Sore muscles (neck, shoulders)?
Are you satisfied with your teeth's appearance?
Would you like to keep all your teeth all your life?
Do you feel nervous about having dental treatment?

If so, what is the biggest concern?
Have you ever had an upsetting dental experience?

YesNo
If yes, please describe
Is there anything else about having dental treatment that you would like us to know?

YesNo
If yes, please describe
MEDICAL HISTORY
Patient Name:

First NameLast Name
Patient Account Number:
Medical Alert:
1. Have you been under the care of a medical doctor during the past two years?

YesNo
If yes, for what?
Physician's Name:
Phone Number:
Please enter a valid phone number.
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
2. Have you taken any medication or drugs during the past two years?

YesNo
3. Are you taken any medication, drugs, or pills now?

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

YesNo
If yes, please list:
5. Have you been a patient in the hospital during the past five years?

YesNo

6. Indicate which of the following you have had, or have at present.

	Yes	No
Heart (Surgery, Disease, Attack)
Chest Pain
Congenital Heart Disease
Heart Murmur
Mitral Valve Prolapse
Artificial Heart Valve
Heart Pacemaker
Rheumatic Fever
Arthritis/Rheumatism
Cortisone Medicine
Swollen Ankles
Stroke
Diet (Special/Restricted)
Artificial Joints (hip, knee, etc.)
Kidney Trouble
Ulcers
Diabetes
Thyroid Problems
Glaucoma
Contact Lenses
Emphysema
Chronic Cough
Tuberculosis
Asthma
Hay Fever
Latex Sensitivity
Allergies or Hives
Sinus Trouble
Radiation Therapy
Chemotherapy
Tumors
Hepatitis A (infectious) B (serum)
Venereal Disease
A.I.D.S
H.I.V Positive
Cold Sores/Fever Blisters
Blood Transfusion
Hemophilia
Sickle Cell Disease
Bruise Easily
Liver Disease
Yellow Jaundice
Neurological Disorders
Epilepsy or Seizures
Fainting or Dizzy Spells
Nervous/Anxious
Psychiatric/Psychological Care

7. Do you use more than two pillows to sleep?

YesNo
8. Have you lost or gained more than 10 pounds in the past year?

YesNo
9. Do you have or have you, had any disease, condition, or problem, not listed?

YesNo
If yes, please list:
10. Women. Are you pregnant?

YesNo
If yes, Months No.
Nursing?

YesNo
Taking birth control pills?

YesNo
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.
Patient/Guardian Signature:*

Clear
Date:

MonthDayYear
Date
History Review:
Doctor Signature:*

Clear
Date:

MonthDayYear
Date
STATEMENT OF PRIVACY PRACTICES
Our office is dedicated to protect the privacy rights of our patients and the confidential information en trusted to us. The commitment of each employee to ensure that your health information is never compromised is a principle concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights.

Protecting Your Personal Healthcare Information

We use and disclose the information we collect from you only as allowed by the Health Insurance Port ability and Accountability Act and the state of Florida. This includes issues relating to your treatment, payment, and our dental care operations. Your personal health information will never be otherwise given to anyone--even family members--without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you chooses, for any purpose.

Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released.

Collecting Protected Health Information

We will only request personal information needed to provide our standard of quality dental care, when lab cases are involved and shared only as needed with your primary physician or specialist when referred, and named family members with your permission. Your personal information will always be protected to the full extent of the law.

Disclose of your Protected Health Information

As stated above, we may disclose information as required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing purposes without your written consent.

We may use and/or disclose your information to communicate reminders about your appointments including voicemail messages, text messages, answering machines, and postcards.

Patient Rights

You have a right request copies of your healthcare information; to request copies in a variety of mats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify that U.S. Department of Health and Human Services.

We thank you for being a patient at Kevin V. Diep, DMD, PA. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.
Acknowledgement of Receipt of Statement of Privacy Practices
I acknowledge that I have received a copy of the Statement of Privacy Practices for the office of Kevin V. Diep, DMD, PA. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and the duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Kevin V. Diep, DMD, PA. reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.

ADDITIONAL DISCLOSURE AUTHORITY

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below:
ANY MEMBER OF MY IMMEDIATE FAMILY

YesNo
SPOUSE ONLY

YesNo
OTHERS

YesNo
PLEASE SPECIFY
Name of Patient or Personal Representative
Signature of Patient or Personal Representative*

Clear
Date

MonthDayYear
Date
Description of Personal Representative's Authority
OFFICE USE ONLY BELOW THIS LINE

RECORD OF ACKNOWLEDGEMENT NOT OBTAINED
Provided Prior To Treatment

YesNo
Date Provided:

MonthDayYear
Date
Reason for Denial:
Should be Empty:

PATIENT REGISTRATION

IF THIS APPOINTMENT IS FOR YOU START HERE

IF THIS APPOINTMENT IS FOR CHILD START HERE

IF YOUR CHILD'S LAST NAME AND/OR ADDRESS ARE NOT THE SAME AS YOURS. FILL IN THE TOP BOX ALSO.

DENTAL INSURANCE

GETTING TO KNOW YOU

IS ANOTHER MEMBER OF YOUR FAMILY OR RELATIVE A PATIENT AT OUR OFFICE?

ACCOUNT INFORMATION

YOU

YOUR SPOUSE

CONSENT FOR TREATMENT

DENTAL HISTORY

MEDICAL HISTORY

STATEMENT OF PRIVACY PRACTICES

Acknowledgement of Receipt of Statement of Privacy Practices

OFFICE USE ONLY BELOW THIS LINE