Form

1. Are you currently under the care of a physician for any condition?Yes   No 
2. Are you currently taking any medication?   Yes   No         
3. If yes, list the medications you are taking   list of medications   
4. Are you allergic to any medication?     Yes   No      
5.Have you had any recent medical treatment?    Yes   No   
6.Have you ever had prolonged bleeding from a cut or wound?   Yes   No   
7.Have you ever had any difficulty with previous dental treatment?    Yes   No   
8.Please check the name of any of the following which you have had: 
ArthritisGlaucomaHyper-or Hypothyroid Heart DiseaseEmphysemaHepatitis or JaundiceRheumatic Fever AsthmaSyphilis or Venereal Disease Heart Murmur Hay Fever/Sinus Epilepsy Cardiac PacemakerTuberculosis or Lung DiseasePolio or Muscular DiseaseChest PainDiabetesCancerHeart SurgeryMitro Valve ProlapseTreatment by X-ray or RadiationJoint ImplantKidney or Bladder ProblemTonsils RemovedHigh Blood PressureBlood Disease UlcersStrokeHIVDo you use Drugs               

How long since your last dental visit?   How long since your last dental visit?    
Last Cleaning?   Last Cleaning?   Last full set of X-rays?   Last full set of X-rays?   
Do Your gums bleed?   Do Your gums bleed?    
Have you ever been told that you have gum disease?   Have you ever been told that you have gum disease?   
Any problems with your breath?   Any problems with your breath?   
Any loose teeth?   Any loose teeth?   
Are you aware of clenching and grinding your teeth?   Are you aware of clenching and grinding your teeth?   

SignatureSignature   Credit Cards Accepted

      
Emotional Concerns   
Fear   Time   Service-Ability   Cost   Health   Appearance         

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. 

PLEASE REVIEW IT CAREFULLY. 

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. 

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 04/14/03, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

______________________________________________________________________________________________________________________

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and healthcare operations. For example: 

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. 

Payment: We may use and disclose your health information to obtain payment for services we provide to you. 

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. 

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described on this Notice. 

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of the Notice. We may disclose you health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. 

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgement disclosing only health information that is directly relevant to the person's involvement on your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. 

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorizations. 

Required by Law: We may use or disclose your health information when we are required to do so by law. 

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. 

National Security: We may disclose to military authorities the health information of Armed Forces personnel
under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances. 

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).   Signature   

PATIENT RIGHTS 

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other that photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information.) You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $__ for each page, $__ per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information on that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure. 

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other that treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more that once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. 

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). 

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. 

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.  

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

I, Name , have received a copy of this office's Notice of Privacy Practices.

1. I hereby authorize the Doctor or designated staff to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the Doctor to make a thorough diagnosis of: blanks's needs.

2. Upon such diagnosis, I authorize the 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 anesthetic, 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 give consent to the Doctor's or designated staff's use and disclosure of any oral, written, or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment, and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.

5. 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. If insurance is filed for me, an estimation will be given, and I agree to pay the remaining amount insurance does not cover at the time of my appointment.

SIGNATURE

I, Name , have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations. 

Signature:  Signature   Date:Date   If this Consent is signed by a person representative on behalf of the patient, complete the following: 

Personal Representative's Name: Name     
Relationship to Patient:   Relationship to Patient   

Consent for Communication of Protected Health Information 

I, Name give my consent to Dr. Sam Harouni, DDS and staff to release Protected Health Information to the people or facilities listed below. This is to include any specialist referred to for diagnostic and/or treatment and lab results.   

Name   Name   
Name   Name   
Name   Name   
Or,   Name   No other persons. Initial