New Patient Registration

Patient Information
Sender
Patient's Name*

First NameMiddle NameLast Name
Preferred Name / Nickname
Gender*
Please specify:
Date of Birth*

MonthDayYear
Date
Marital Status
Social Security Number
Upload a photo of yourself (selfie)*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Mobile Phone*
Please enter a valid phone number.Format: (000) 000-0000.
Other Phone (Home, Business)
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
Please upload an image of the front of your ID or Driver's License:
Please provide us with an emergency contact and let us know if there are any other individuals you authorize us to speak with about your dental care. This information helps us reach someone quickly in case of an urgent situation, and allows us to share important details with trusted individuals you designate:
Emergency Contact:*
Other Authorized Contacts:
Consent for Communication & Protected Health Information Sharing
I, Full Name* , hereby authorize Smiles of Boca (Rafael Morales, DDS PA) and their staff, to contact me via mobile phone, home phone, voicemail, SMS text message, email, and/or fax for matters related to my dental care, and to disclose, release, and share my protected health information (PHI) with my listed emergency contact, and any additional individuals I have listed as authorized contacts elsewhere on this form. These communications may include, but are not limited to:
- Appointment reminders and scheduling
- Diagnostic results (including x-rays and photographic images)
- Treatment plans and care follow-up
- Medications
- Communication with other dental or medical providers involved in my care, including referrals and coordination of treatment
- Billing & Payment information
- Insurance claims, pre-determinations and other insurance-related communications
- Administrative purposes and general practice updates
I understand that email and SMS text message communication is not always secure and may be intercepted or accessed by unauthorized individuals. By providing my email address, mobile number, and signing this form, I authorize Smiles of Boca (Rafael Morales, DDS PA) to send appointment reminders, treatment-related information, and other health-related communications to me and to the individuals I have authorized to receive my information, via email and SMS text message. I understand that some of these communications may involve the use of third-party services (such as automated reminders or digital form tools), which have been selected to comply with applicable privacy and security standards.

I further acknowledge that:
- My information will not be sold
- Any information shared with third parties will not be used for their own marketing purposes.
- My information may be used by Smiles of Boca for occasional practice-related marketing communications, such as new services or special offers.
- I have the option to receive information through other means (such as postal mail)
- I may opt out of non-essential or marketing communications at any time by notifying the office in writing.
Date*

MonthDayYear
Date
Signature*

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Dental Insurance

Rows	YES	NO
Do you currently have dental insurance?

Insurance Member #
Insurance Group #
Take photos of the front and back of my insurance cardUpload a document (e.g., insurance letter or digital card)
Insurance card Front*
Insurance card Back*
Insurance Card Document Upload:*

Cancelof
I, Full Name* , authorize the insurance company listed on this form to pay directly to Rafael Morales, DDS PA (dba. Smiles of Boca) all insurance benefits otherwise payable to me for services rendered. I also authorize the use of this signature for all insurance submissions and for the release of any information necessary to secure payment of benefits.
Date*

MonthDayYear
Date
Signature*

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Medical History - Women

Please answer each of the following questions by selecting 'Yes', 'No', or 'N/A' (Not applicable or unsure) *

Rows	YES	NO	N/A
Are you pregnant or think you may be pregnant?
Are you nursing?
Are you currently taking birth control pills?

Medical History - Acknowledgment & Attestation
I, Full Name* , confirm that I have reviewed the information provided in this medical history form, and to the best of my knowledge, it is accurate and complete. I acknowledge that any questions or concerns I may have had about the inquiries in this form have been addressed to my satisfaction. I understand that this information will be used by the staff at Smiles of Boca to determine appropriate and healthful treatment.

I agree to promptly inform the staff at Smiles of Boca of any changes in my medical status.
Date*

MonthDayYear
Date
PatientParent or Guardian
If you are the Parent or Guardian of the patient, please provide your name and specify your relationship to the patient:*
Full Name
Relationship to Patient*
Please specify:*
Signature*

Clear

Consent to Privacy Practices - HIPAA
I, Full Name* , understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent form, I authorize this practice to disclose my protected health information to carry out:
- Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
- Obtaining payment from third party payers (e.g. dental insurance company)
- The day‐to‐day healthcare operations of the practice.
I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that the practice reserves the right to change the terms of this notice from time to time and that I may contact the practice at any time to obtain the most current copy of this notice.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and healthcare operations, but that the practice is not required to agree to these requested restrictions. However, if agreed, the practice is then bound to comply with this restriction.
I understand that I may revoke this consent, in writing at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
Date*

MonthDayYear
Date
Signature*

Clear

Appointment Policy
At Smiles of Boca, we value your time and strive to provide the highest quality dental care in a respectful and efficient manner. To ensure smooth scheduling and the best experience for all our patients, we kindly ask you to review and adhere to the following appointment policies. Your understanding and cooperation help us deliver exceptional service to you and your family.
- A scheduled appointment is reserved specifically for your dental needs. Any changes to this appointment affects many patients. If a cancellation is unavoidable, please call our office at least 24 hours in advance so that we may give that time to another patient. If an appointment is cancelled or broken with less than 24 hours’ notice, a $60 fee will be charged to your account. A broken appointment means a no show without notice.
- We understand family and personal emergencies. In case of a cancellation via phone call, text message or email, on the same day or within 24 hours of your appointment due to a true emergency, the charge of $60.00 will be waived.
- For your convenience, we offer multiple forms of payment: cash, check, credit card or third-party no-interest financing (i.e., Care Credit). A 50% deposit is required to reserve a major treatment appointment (crowns, bridges, implants, periodontal surgery, root canals, extractions of wisdom teeth, etc.) or any appointment longer than one (1) hour. The remaining 50% is expected to be paid at the time of your first visit to start treatment.
- We strive to see all patients on time for their scheduled appointment. There are times when our schedule is delayed in order to accommodate an injured patient or an emergency. Please accept our apology in advance should this occur during your appointment. We will do the exact same if you or a member of your family is in need of emergency treatment.
- Once you schedule your appointment, you are responsible to keep record of it; however, as a courtesy and support to all our patients, we’ll contact you 1 or 2 days before your appointment to give you a reminder of your appointment via text message, e-mail and/or phone call. We ask you kindly to re-confirm with us your attendance.
- Please plan to arrive at least 5 minutes prior to your scheduled appointment. This will allow time to complete any additional paperwork and see you on time.
- If you arrive 15 minutes or more late for your appointment, you may be asked to reschedule for the next available appointment time.
If at any time you have questions regarding these or any of our policies, please feel free to ask our staff or call our office. We are here to help in any way we can. We appreciate you entrusting your dental health and that of your family to us.
Name*

First NameLast Name
Date*

MonthDayYear
Date
Signature*

Clear

Consent for Treatment
I, Full Name* , hereby authorize Dr. Rafael Morales and the staff of Smiles of Boca (Rafael Morales, DDS PA) to perform any necessary dental examinations, diagnostics, and treatments deemed appropriate for my oral health care. I also authorize the use of local anesthetics, medications, and any other necessary therapeutic measures to ensure my comfort and care.

I understand and acknowledge that:
- The nature, purpose, and potential risks of any proposed treatment will be explained to me, and I will have the opportunity to ask questions before proceeding.
- I have the right to accept or decline any recommended treatment.
- During the course of treatment, conditions may arise that require additional or different procedures, and I authorize the dentist and staff to perform such procedures if deemed necessary.
- No guarantees or assurances can be made regarding the outcome of any treatment.
Date*

MonthDayYear
Date
Signature*

Clear
Should be Empty:

Rows	YES	NO	N/A
Do you brush your teeth more than once a day?
Do you floss regularly (at least once a day or every other day)?
Do you use mouthwash?
Do you frequently consume sugary foods or drinks??
Are you currently experiencing any dental pain, sensitivity (to hot, cold, sweets, or pressure), or discomfort in your teeth, gums, or jaw?
Do your gums bleed when brushing or flossing?
Have you ever had any gum treatments (e.g., deep cleaning, gum surgery)?
Have you ever had orthodontic treatment (e.g., braces, Invisalign)?
Do you currently wear an orthodontic retainer?
Do you bite your nails, chew ice, or regularly chew on pens/pencils or other objects?
Do you clench or grind your teeth?
Do you experience any earaches, neck pain, jaw clicking, popping or discomfort?
Do you snore or wake up frequently during the night?
Do you have trouble sleeping or staying asleep?
Do you currently wear a nightguard or any appliance for TMJ disorders, snoring or sleep apnea?
Do you currently wear, or have you ever worn, full or partial removable dentures?
Do you ever experience sores, ulcers, dry mouth, or other unusual issues in your mouth?
Have you ever had a serious injury to your head, face, or mouth?

Rows	YES	NO	N/A
Congestive Heart Failure (CHF)
Artificial Heart Valve or History of Endocarditis
Heart Attack, Coronary Artery Disease, or Heart Surgery (e.g., stents, bypass)
Congenital Hear Disease
High Blood Pressure (Hypertension)
Low Blod Pressure (Hypotension)
Heart Arrhythmias, Heart Murmur or Pacemaker
Stroke or Blood Clots (e.g., DVT)

Rows	YES	NO	N/A
Asthma
Bronchitis
Emphysema
Sinus trouble
Tuberculosis (TB)
Sleep Apnea

Rows	YES	NO	N/A
Anxiety
Depression
Epilepsy
Mental Health Disorders
Neurological Disorders
Post-Traumatic Stress Disorder (PTSD)
Traumatic Brain Injury or Concussion

Rows	YES	NO	N/A
Arthritis
Chronic Pain
Diabetes (Type I or II)
Eating Disorder
Hepatitis, jaundice or liver disease
Immune Deficiency
Kidney problems
Osteoporosis
Rheumatoid Arthritis
Sexually Transmitted Infection (STI)
Thyroid Problems

Patient Information

Consent for Communication & Protected Health Information Sharing

Dental Insurance

Dental History

Medical History - General

Medical History - Women

Medical History - Lifestyle Habits

Medical History - Medications

Medical History - Specific

Medical History - Acknowledgment & Attestation

Consent to Privacy Practices - HIPAA

Appointment Policy

Consent for Treatment

Rows	YES	NO	N/A
Are you currently under the care of a physician?

Rows	YES	NO	N/A
Have you had a serious illness, surgery, or hospitalization in the past 5 years?

Rows	YES	NO	N/A
Do you have any known allergies, or have you ever had an allergic reaction?

Rows	YES	NO	N/A
Have you ever been advised to take antibiotics or other medications before dental procedures due to a medical condition (e.g., heart condition, joint replacement)?

Rows	YES	NO	N/A
Do you use, or have you ever used, tobacco products (smoking, snuff, chew, bidis)?

Rows	YES	NO	N/A
Do you use any controlled substances (drugs such as marijuana, cocaine, or other substances), for either medicinal or recreational reasons?

Rows	YES	NO	N/A
Are you currently taking, or have you recently taken, any prescription or over-the-counter pain relief medications?

Rows	YES	NO	N/A
Have you ever taken, are you currently taking, or are you scheduled to take an antiresorptive medication for osteoporosis, cancer, or other bone-related conditions?

Rows	YES	NO	N/A
Are you currently taking hormone replacement therapy (HRT)?

Rows	YES	NO	N/A
Blood Disorders (e.g., Hemophilia, Sickle Cell, Factor V Leiden)
Anemia
Recent Blood Transfusion

Rows	YES	NO	N/A
AIDS or HIV infection
Lupus

Rows	YES	NO	N/A
Gastrointestinal Disease
GE (Acid) Reflux/persistent heartburn (GERD)
Stomach ulcers

Rows	YES	NO	N/A
Are there any other medical conditions, diagnoses, or health concerns not listed above that we should be aware of?