New Patient HIPAA English

Patient Information

All information is CONFIDENTIAL. Fields marked with a * are required
Today's Date

MonthDayYear
SS# / SIN
Patient #
Patient Name*

First NameMiddle NameLast Name
Patient Address*

Street Address

Street Address Line 2

CityState

Zip Code
Patient Birthdate*

MonthDayYear
Patient Email address
Cell phone
Home phone
Marital status

MinorSingleMarriedDivorcedPartneredWidowedSeparatedOther
Patient or parent/guardian's employer
Work phone
Spouse or parent/guardian's name
Spouse's or parent/guardian's employer name
Spouse's or parent/guardian's work phone
Whom may we thank for referring you ?
Person to contact in case of emergency
Emergency contact phone number

Responsible Party
Name of the person responsible for patient's account
Relationship to patient
Birthdate

MonthDayYear
Address

Street Address

Street Address Line 2

CityState

Zip Code
SS# / SIN
Driver License #
Cell phone
Home phone
Name of employer
Work phone
Email address
Is this person currently a patient in our office?

YesNo

Insurance Information
Name of insured
Relationship to patient
Birthdate

MonthDayYear
SS# / SIN
Name of employer
Work phone
Please enter a valid phone number.
Insurance company
Policy/ID #
Group #
Do you have any additional dental insurance?*

Insurance Information #2
Name of insured
Relationship to patient
Birthdate

MonthDayYear
SS# / SIN
Name of employer
Work phone
Please enter a valid phone number.
Insurance company
Policy/ID #
Group #

Authorization and Release
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information, inluding the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
Signature of patient (or parent/guardian if minor)

Clear
Date

MonthDayYear

Financial Policy
We at Dental Arts are proud to be part of a team whose primary mission is to deliver the finest and most comprehensive health care available today. Your clear understanding of our Financial Policy is important to our professional relationship.
- New Patient must fill out patient information forms prior to seeing the doctor.
- We will request to photocopy your Insurance card (s) and Driver’s License for your record.
- Co-payments and annual deductibles must be collected the same day services are rendered.
- If your insurance company rejects or deny your claim for services rendered, it is your responsibility to pay the remaining balance.
- We reserve the right to charge a fee of $25.00 for last minute cancellations or no show appointment.
Payment options

In addition, we are also dedicated to making top-quality care as cost-effective as possible. To assist you with your healthcare investment, we provide the following payment options:
1. Cash --- includes personal checks.
2. Visa/MasterCard/Amex/Discover --- we accept credit cards as payment for treatment.
3. Care Credit--- the financing plan we offer as a separate line of credit to cover your and your family members’ healthcare needs. With CareCredit :* you enjoy these benefits:
  - Flexible financing options
  - Credit decision usually only takes a few minutes
  - No annual fees or prepayment penalties
We are happy to provide you the above options to allow you to make convenient, low monthly payments. If CareCredit is your preferred option, you can begin any necessary treatment immediately and spread the payments out over time*.

We are pleased you have chosen to become a member of our patient family.

*Subject to credit approval.
Responsible party signature

Clear
Date

MonthDayYear

Acknowledgment of Receipt of Privacy Practices Notice
I, Patient name acknowledge that I have received a Notice of Privacy Practices from the above named practice. (Refer to Privacy Policy page)
If a personal representative signs this authorization on behalf of the individual, complete the following:
Personal representative's name
Relationship to individual
Describe your good faith effort to obtain the individual’s signature on this form:
Describe the reason why the individual would not sign this form:
I attest that the above information is correct. Patient or Legal Guardian Signature:

Clear
Date

MonthDayYear
Should be Empty:

	Yes	No
1. Are you under medical treatment now?
2. Do you use controlled substances?
3. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?
4. Are you taking any medication(s) including non-prescription medicine?
5. Have you ever taken Fern-Phen/Redux?
6. Do you use tobacco?
7. Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates?
8. Have you taken Viagra, Revatio, Cialis or Levitra in the last 24 hours?
9. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

	Yes	No
High Blood Pressure
Heart Attack
Rheumatic Fever
Swollen Ankles
Fainting/ Seizures
Asthma
Low Blood Pressure
Epilepsy/ Convulsions
Leukemia
Diabetes
Kidney Diseases
AIDS/ HIV infection
Thyroid Problem
Heart Disease
Cardiac Pacemaker
Heart Murmur
Angina
Emphysema
Cancer
Arthritis
Hepatitis/ Jaundice
Chest Pains
Easily Winded
Stroke
Hay Fever/ Allergies
Tuberculosis
Radiation Therapy
Glaucoma
Recent Weight Loss
Liver Disease
Valve Replacement
Respiratory Problems
Mitral Valve Prolapse
Anemia
Frequently Tired
Stomach Troubles / Ulcers
Joint Replacement / Implant
Sexually Transmitted Disease

	Yes	No
Local Anesthetics (e.g. Novocain)
Penicillin or any other Antibiotics
Sulfa Drugs
Barbiturates
Sedatives
Iodine
Aspirin
Any Metals
Latex Rubber

	Yes	No
Are you pregnant or think you may be pregnant?
Are you nursing?
Are you taking oral contraceptives?

	Yes	No
Do your gums bleed while brushing or flossing?
Are your teeth sensitive to hot or cold liquids/foods?
Are your teeth sensitive to sweet or sour liquids/foods?
Do you feel pain to any of your teeth?
Do you have any sores or lumps in or near your mouth?
Have you had any head, neck or jaw injuries?
Have you ever experienced clicking of you jaw?
Have you ever experienced pain in your jaw (joint, ear, side of face)?
Have you ever experienced difficulty in opening or closing your jaw?
Have you ever experienced difficulty in chewing?
Do you have frequent headaches?
Do you clench or grind your teeth?
Do you bite your lips or cheeks frequently?
Have you ever had any difficult exctractions in the past?
Have you ever had any prolonged bleeding following extractions?
Have you had any orthodontic treatment?
Do you wear dentures or partials?
Have you ever received oral hygiene instructions regarding the care of your teeth and gums?
Do you like to smile?

Patient Information

Responsible Party

Insurance Information

Insurance Information #2

Patient Medical History

Patient Dental History

Authorization and Release

Financial Policy

Payment options

Acknowledgment of Receipt of Privacy Practices Notice