NEW PATIENT FORM - BIG ISLAND

Patient Information
Patient's Name*

First NameLast Name
Patient's Preferred Name
Parent or Guardian's Name
If patient is a minor, please provide parent or guardian's name.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Phone Number*
Date of Birth*

MonthDayYear
Gender
Pronoun
Who may we thank for referring you?

Responsible Party Information
Responsible Party's Name

First NameLast Name
Marital Status
Housing Status
Mailing Address

Street Address

Street Address Line 2

CityState

Zip Code
Email
Mobile Phone Number
Work Phone Number
Relationship to Patient
Birth Date

MonthDayYear
Occupation
Employer
Number of Years Employed
Spouse's Name

First NameLast Name
Spouse's Mobile Phone Number
Spouse's Relationship to Patient
Spouse's Birth Date

MonthDayYear
Spouse's Occupation
Spouse's Employer
Spouse's Number of Years Employed

Dental Insurance Information
Insurance Policy Holder's Name

First NameLast Name
Insurance Company
Subscriber / Member ID
Group ID
Union Local Number
Insurance Company Address

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Company Phone Number
Policy Holder's Employer
Dual Coverage?
Insurance Policy Holder's Name

First NameLast Name
Insurance Company
Subscriber / Member ID
Group ID
Union Local Number
Insurance Company Address

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Company Phone Number
Policy Holder's Employer

Emergency Contact Information
Name of Emergency Contact

First NameLast Name
Relationship to the Patient
Emergency Contact's Address

Street Address

Street Address Line 2

CityState

Zip Code
Emergency Contact's Phone Number

HIPAA Consent
Prior to using or disclosing your protected health information to carry out treatment, payment or health care operations, Hawaii Smile Designs/Dr. Aaron Miyai DMD is required under federal law to obtain your consent. Please review this consent. If you agree with its terms, please sign and date this consent below. Should you desire a more complete description of the permissible uses and disclosures of your protected health information, you have the right to review a Notice of Privacy Practices (the “Notice”) prior to signing this consent. By signing this consent, you agree that we may use or disclose your protected health information to carry out treatment, payment or health care operations. We take records for our diagnostic purpose only. If you wish to have a copy of these records for other purposes or have them transferred to another orthodontic office then there will be a $365.00 + tax fee to be collected prior to releasing the records. Your insurance will be billed for diagnostic records taken by our office, you are responsible for any unpaid portion. By providing listed phone numbers (i.e. home/cell and/or email address) on your patient information sheet, you consent to our practice using the phone numbers/email address to contact you regarding appointments, treatment, insurance, finances and your account via text message, phone calls or electronic communications. You have the right to request restrictions how your protected health information is used or disclosed to carry out treatment, payment or health care operations. However, we are not required to agree to such restrictions. If we agree to a restriction that you request, such restriction will be binding. You have the right to revoke this consent in writing, except to the extent that we have taken action in reliance on your consent. This consent form will be kept in your patient file for a period of six (6) years.

Clear
By signing below, I hereby certify that I have read the provisions set forth in this HIPAA consent. I understand and agree to the terms of this consent. I understand that this consent is between you and Hawaii Smile Designs. No other individuals/organizations have permission to obtain my confidential information under this consent.
Signature Date

MonthDayYear
Date
Should be Empty: