www.royaldentalwesthills.com - New Patient Forms

New Patient Forms
Today’s Date *

MonthDayYear
Date
Revised Date

MonthDayYear
Date
Referred By
In Order To Serve You Properly, We Need The Following Information. All Information Is Strictly Confidential. Please Print Clearly.
Patient’s Name*

First NameMiddle NameLast Name
Nickname
Date of Birth*

MonthDayYear
Social Security Number
Marital Status
Address*
State, City, Zip Code
Home Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Cell Phone Number*
Please enter a valid phone number.
Email Address*
example@example.com
Employer
Employer’s Address
State, City, Zip Code
Name of Spouse (or Parent)
Address
State, City, Zip Code
Social Security Number of Spouse
Phone Number*
Please enter a valid phone number.
Chief Complaint / Reason
Date of Last General Physical Exam
List any allergies you have (Drugs, Food, Hay Fever, Other)
List any medications you are taking
Describe any conditions we should know about
Do you have high blood pressure?
Diabetes
Primary Insurance Company
Policy Number
Subscriber Name
Social Security Number
Do you have insurance through your employer?*

YesNo
If " Yes" ID Number*
Any Secondary Insurance?*

YesNo
If " Yes" Company *
Address to Send Claim
I understand that I am financially responsible for all charges for services to me. Including the balance remaining after payment of possible insurance benefits
Signature of (Patient, or Parent if Minor) *

Clear
Name of (Patient, or Parent if Minor) *

First NameLast Name
Date*

MonthDayYear
Date
I authorize the release of any medical information necessary to process this claim.
Signature

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Name

First NameLast Name
Date

MonthDayYear
Date

Patient’s Acknowledgement of Receipt of Dental Materials Fact Sheet
I, {patientsName} , acknowledge I have received from Dr. Shoffet-Yaghoubian a copy of the Dental Materials Fact sheet dated October 2001.
Patient Signature*

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Patient Name*

First NameLast Name
Date*

MonthDayYear
Date
Acknowledgement of Receipt of Notice of Privacy Practices
You May Refuse to Sign This Acknowledgement
I, full name , have received a copy of the Notice of Privacy Practices.
Signature

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Print Name

First NameLast Name
Date

MonthDayYear
Date
If this acknowledgement is signed by a personal representative on behalf of the patient, complete the following
Personal Representative’s Name
Relationship to Patient
Signature*

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Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

New Patient Forms

In Order To Serve You Properly, We Need The Following Information. All Information Is Strictly Confidential. Please Print Clearly.

Do you have or have you had any of the following:

Cardiovascular Disorders

Respiratory Disorders

Musculo -Skeletal / CNS / Develop Mental Disorders

Gastrointestinal / Genitourinary Disorders

Hematologic / Endocrine / Immune Disorders

Psychiatric

Family History (Grandparents, Parents, Sisters, Brothers, Children

Allergies

Females

Patient’s Acknowledgement of Receipt of Dental Materials Fact Sheet

Acknowledgement of Receipt of Notice of Privacy Practices

You May Refuse to Sign This Acknowledgement