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HIPAA NOTICE OF PRIVACY PRACTICES

 

I authorize Jennifer Ngai, DDS to release my general and health information along with my dental services performed under the following terms and conditions:

If you sign this authorization, you can revoke it at any time. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us that your authorization is being revoked. Send this “Notice to Revoke” to our office address, email, or fax.

If you want to review or get photocopies of your health or general information, send a written request to the office. There will be a charge to photocopy and mail your information.

OUR NOTICE OF PRIVACY PRACTICES: By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by the law. If we change our Notice of Privacy Practices, the new privacy practices will apply to your health and general information that we already have, as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office and will have copies available for you at no charge.

COMPLAINTS: If you think that we have not properly respected the privacy of health and general information, you are free to complain to us in writing to our address and we will respond to your complaint within 30 days of receipt.

HIPAA: Health Insurance Portability & Accountability Act of 1996* this Act requires all health care records and other individually identifiable health information used or disclosed to us in any form, whether electronically, on paper, or orally to be kept confidential. This federal law gives you significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by law, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.

We can without specific written authorization: permitted to use and disclose your healthcare records for the purposes of treatment, payment and healthcare operations.

Treatment: By providing, coordinating, or managing healthcare and related services by one or more healthcare providers.

Payment: By obtaining reimbursement for services, confirming coverage, billing, collection and utilization reviews.

Healthcare Operations: By including the business aspects of running our practice, such as in training purposes or quality assessment.

In case of an emergency or your incapacity, we will use our professional judgment in disclosing only the protected health and general information necessary to facilitate needed care. In addition, we may use your confidential information to remind you of an appointment, sending reminder postcards, or leaving messages at home or work.

We may disclose your health information for public health oversight activities, judicial or administrative proceedings, in response to a subpoena, court orders, to military authorities or Armed Forces Personnel, to federal officials for lawful intelligence, counterintelligence, and other national security activities, or correctional institutions or law enforcement officials and/or to report suspected abuse, neglect, or domestic violence.

You may request restrictions: on uses and disclosures of your health information to family members, other relatives, close personal friends, or any other person you identify in writing. We will abide by it until you contact us in writing to remove the restrictions.

You have the right: to access, inspect and receive a copy of your health information, with limited exceptions. A reasonable fee may be assessed. You may also receive a list of disclosures of your health information made outside of treatment, payment, or healthcare operations.

My signature below confirms that I have been informed of my rights to privacy regarding my general and health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I have been given the right to review and receive a copy of this Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and I may contact this office for a current copy of the Notice of Privacy Practices. 

 

FINANCIAL POLICY

 

The following is a statement of our FINANCIAL POLICY which we request you to read and sign prior to any treatment. We invite you to discuss our fees or financial policies with us. We are always happy to answer any questions or concerns regarding our policies, service fees, insurance claims, or billing questions.

INSURANCE: We will be glad to submit your claim to your insurance company. To do this we must have complete and accurate insurance information. Please bring your insurance card, your driver’s license or state ID to your appointment. NOTE: Your insurance policy is a contract between you and your insurance company. You are ultimately responsible for payment on all services rendered. We recommend that you contact your insurance company regarding your dental coverage, exclusions, and limitations, that way there are no surprises.

CO-PAYMENTS: All co-payments are due at the time of service.

NO INSURANCE: If you do not have dental insurance, please be prepared to pay in full at the time of service.

PAYMENT: You are responsible to pay for all services rendered (even if your insurance denies payment). Once your insurance company has processed the claim, if there is a balance due we will send you a statement. You have 30 days from the date of your statement before your account is considered delinquent. If you are not able to pay within 30 days, please call our front office to make financial arrangements, plus your account maybe assessed with interest fee of 1.5% on each subsequent statement until the balance is paid in full. We accept Visa, MasterCard, AMEX, or Discover. There is a $35.00 charge for all returned checks.

ALL ACCOUNTS OVER 60 DAYS (without prior financial arrangement): will be considered for collections. If you need additional time to pay your balance, please call our front office to make financial arrangements. If we do not hear from you and you are delinquent on your account, then you will turn over to a collection agency. The collection agency will charge their additional fees.

MISSED OR CANCELLED APPOINTMENTS: Please help us serve you better by keeping your scheduled appointments. There is a charge of $50.00 for a missed or late cancellation. We are asking for 48 hour prior notice to cancel your appointment. This will allow other patients an opportunity to come in for their care with adequate notice.

LATE ARRIVALS: We are very willing to wait for our patients for a reasonable amount of time. We ask that you call us in a timely manner with an estimate of when you can arrive, so we can adjust our time to your delay. If you are unusually late, we may have to reschedule your appointment, as to not impose on our next patient’s appointment time.

I understand that I am personally responsible for all charges on all services rendered. I authorize Jennifer Ngai, DDS to release any information required to process my claims and I also hereby assign my insurance benefits to be paid directly to Jennifer Ngai, DDS. I agree to pay all reasonable attorney fees, court costs and collection agency fees incurred by Jennifer Ngai, DDS if my account is turned over to Collections. I hereby agree to the terms and conditions as specified above.

 

 

First Patient Name

First Name*

Middle Name

Last Name*

Phone*
First Patient Date of Birth*
First Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)

Cardiovascular
Chest pain/shortness of breath
Blood pressure problem
Heart murmur
Heart valve problem
Taking heart medications
Pacemaker
Blood Related
Easy bruising
Frequent nosebleeds
Abnormal bleeding
Blood disease
Anemia
Allergies
Hay fever
Sinus problems
Taking allergy medications
Asthma
Digestive
Ulcers
Weight gain/loss
Special diet
Constipation/diarrhea
Kidney or bladder problems
Musculoskeletal System
Arthritis
Back or neck pain
Joint replacement
Other
Fainting spells, seizures, or epilepsy
Stroke
Heart attack
Frequent/severe headaches
Thyroid problems
Persistent cough
Swollen glands
Cancer/tumor
Diabetes
Tuberculosis/respiratory disease
Hepatitis, jaundice, or liver problems
Herpes
Other STDs
HIV/AIDS
Neurological disease
History of head injury
Anxiety
Known Allergic Reactions *
Local anesthetics
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin, Acetaminophen, or Ibuprofen
Codeine, Demerol, or other narcotics
Reaction to metals
Latex or rubber dam
Fluoride
No known drug allergies
Women Only
Contraceptives/hormones
Pregnant
Nursing
Menopause
HPV exposure
Are you currently taking any anticoagulants or blood thinners?*
No
Yes

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
First Patient Signature*
Second Patient Name

First Name*

Middle Name

Last Name*
Second Patient Date of Birth*
Second Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)

Cardiovascular
Chest pain/shortness of breath
Blood pressure problem
Heart murmur
Heart valve problem
Taking heart medications
Pacemaker
Blood Related
Easy bruising
Frequent nosebleeds
Abnormal bleeding
Blood disease
Anemia
Allergies
Hay fever
Sinus problems
Taking allergy medications
Asthma
Digestive
Ulcers
Weight gain/loss
Special diet
Constipation/diarrhea
Kidney or bladder problems
Musculoskeletal System
Arthritis
Back or neck pain
Joint replacement
Other
Fainting spells, seizures, or epilepsy
Stroke
Heart attack
Frequent/severe headaches
Thyroid problems
Persistent cough
Swollen glands
Cancer/tumor
Diabetes
Tuberculosis/respiratory disease
Hepatitis, jaundice, or liver problems
Herpes
Other STDs
HIV/AIDS
Neurological disease
History of head injury
Anxiety
Known Allergic Reactions *
Local anesthetics
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin, Acetaminophen, or Ibuprofen
Codeine, Demerol, or other narcotics
Reaction to metals
Latex or rubber dam
Fluoride
No known drug allergies
Women Only
Contraceptives/hormones
Pregnant
Nursing
Menopause
HPV exposure
Are you currently taking any anticoagulants or blood thinners?*
No
Yes

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Third Patient Name

First Name*

Middle Name

Last Name*
Third Patient Date of Birth*
Third Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)

Cardiovascular
Chest pain/shortness of breath
Blood pressure problem
Heart murmur
Heart valve problem
Taking heart medications
Pacemaker
Blood Related
Easy bruising
Frequent nosebleeds
Abnormal bleeding
Blood disease
Anemia
Allergies
Hay fever
Sinus problems
Taking allergy medications
Asthma
Digestive
Ulcers
Weight gain/loss
Special diet
Constipation/diarrhea
Kidney or bladder problems
Musculoskeletal System
Arthritis
Back or neck pain
Joint replacement
Other
Fainting spells, seizures, or epilepsy
Stroke
Heart attack
Frequent/severe headaches
Thyroid problems
Persistent cough
Swollen glands
Cancer/tumor
Diabetes
Tuberculosis/respiratory disease
Hepatitis, jaundice, or liver problems
Herpes
Other STDs
HIV/AIDS
Neurological disease
History of head injury
Anxiety
Known Allergic Reactions *
Local anesthetics
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin, Acetaminophen, or Ibuprofen
Codeine, Demerol, or other narcotics
Reaction to metals
Latex or rubber dam
Fluoride
No known drug allergies
Women Only
Contraceptives/hormones
Pregnant
Nursing
Menopause
HPV exposure
Are you currently taking any anticoagulants or blood thinners?*
No
Yes

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Fourth Patient Name

First Name*

Middle Name

Last Name*
Fourth Patient Date of Birth*
Fourth Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)

Cardiovascular
Chest pain/shortness of breath
Blood pressure problem
Heart murmur
Heart valve problem
Taking heart medications
Pacemaker
Blood Related
Easy bruising
Frequent nosebleeds
Abnormal bleeding
Blood disease
Anemia
Allergies
Hay fever
Sinus problems
Taking allergy medications
Asthma
Digestive
Ulcers
Weight gain/loss
Special diet
Constipation/diarrhea
Kidney or bladder problems
Musculoskeletal System
Arthritis
Back or neck pain
Joint replacement
Other
Fainting spells, seizures, or epilepsy
Stroke
Heart attack
Frequent/severe headaches
Thyroid problems
Persistent cough
Swollen glands
Cancer/tumor
Diabetes
Tuberculosis/respiratory disease
Hepatitis, jaundice, or liver problems
Herpes
Other STDs
HIV/AIDS
Neurological disease
History of head injury
Anxiety
Known Allergic Reactions *
Local anesthetics
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin, Acetaminophen, or Ibuprofen
Codeine, Demerol, or other narcotics
Reaction to metals
Latex or rubber dam
Fluoride
No known drug allergies
Women Only
Contraceptives/hormones
Pregnant
Nursing
Menopause
HPV exposure
Are you currently taking any anticoagulants or blood thinners?*
No
Yes

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Fifth Patient Name

First Name*

Middle Name

Last Name*
Fifth Patient Date of Birth*
Fifth Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)

Cardiovascular
Chest pain/shortness of breath
Blood pressure problem
Heart murmur
Heart valve problem
Taking heart medications
Pacemaker
Blood Related
Easy bruising
Frequent nosebleeds
Abnormal bleeding
Blood disease
Anemia
Allergies
Hay fever
Sinus problems
Taking allergy medications
Asthma
Digestive
Ulcers
Weight gain/loss
Special diet
Constipation/diarrhea
Kidney or bladder problems
Musculoskeletal System
Arthritis
Back or neck pain
Joint replacement
Other
Fainting spells, seizures, or epilepsy
Stroke
Heart attack
Frequent/severe headaches
Thyroid problems
Persistent cough
Swollen glands
Cancer/tumor
Diabetes
Tuberculosis/respiratory disease
Hepatitis, jaundice, or liver problems
Herpes
Other STDs
HIV/AIDS
Neurological disease
History of head injury
Anxiety
Known Allergic Reactions *
Local anesthetics
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin, Acetaminophen, or Ibuprofen
Codeine, Demerol, or other narcotics
Reaction to metals
Latex or rubber dam
Fluoride
No known drug allergies
Women Only
Contraceptives/hormones
Pregnant
Nursing
Menopause
HPV exposure
Are you currently taking any anticoagulants or blood thinners?*
No
Yes

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Sixth Patient Name

First Name*

Middle Name

Last Name*
Sixth Patient Date of Birth*
Sixth Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)

Cardiovascular
Chest pain/shortness of breath
Blood pressure problem
Heart murmur
Heart valve problem
Taking heart medications
Pacemaker
Blood Related
Easy bruising
Frequent nosebleeds
Abnormal bleeding
Blood disease
Anemia
Allergies
Hay fever
Sinus problems
Taking allergy medications
Asthma
Digestive
Ulcers
Weight gain/loss
Special diet
Constipation/diarrhea
Kidney or bladder problems
Musculoskeletal System
Arthritis
Back or neck pain
Joint replacement
Other
Fainting spells, seizures, or epilepsy
Stroke
Heart attack
Frequent/severe headaches
Thyroid problems
Persistent cough
Swollen glands
Cancer/tumor
Diabetes
Tuberculosis/respiratory disease
Hepatitis, jaundice, or liver problems
Herpes
Other STDs
HIV/AIDS
Neurological disease
History of head injury
Anxiety
Known Allergic Reactions *
Local anesthetics
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin, Acetaminophen, or Ibuprofen
Codeine, Demerol, or other narcotics
Reaction to metals
Latex or rubber dam
Fluoride
No known drug allergies
Women Only
Contraceptives/hormones
Pregnant
Nursing
Menopause
HPV exposure
Are you currently taking any anticoagulants or blood thinners?*
No
Yes

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Seventh Patient Name

First Name*

Middle Name

Last Name*
Seventh Patient Date of Birth*
Seventh Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)

Cardiovascular
Chest pain/shortness of breath
Blood pressure problem
Heart murmur
Heart valve problem
Taking heart medications
Pacemaker
Blood Related
Easy bruising
Frequent nosebleeds
Abnormal bleeding
Blood disease
Anemia
Allergies
Hay fever
Sinus problems
Taking allergy medications
Asthma
Digestive
Ulcers
Weight gain/loss
Special diet
Constipation/diarrhea
Kidney or bladder problems
Musculoskeletal System
Arthritis
Back or neck pain
Joint replacement
Other
Fainting spells, seizures, or epilepsy
Stroke
Heart attack
Frequent/severe headaches
Thyroid problems
Persistent cough
Swollen glands
Cancer/tumor
Diabetes
Tuberculosis/respiratory disease
Hepatitis, jaundice, or liver problems
Herpes
Other STDs
HIV/AIDS
Neurological disease
History of head injury
Anxiety
Known Allergic Reactions *
Local anesthetics
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin, Acetaminophen, or Ibuprofen
Codeine, Demerol, or other narcotics
Reaction to metals
Latex or rubber dam
Fluoride
No known drug allergies
Women Only
Contraceptives/hormones
Pregnant
Nursing
Menopause
HPV exposure
Are you currently taking any anticoagulants or blood thinners?*
No
Yes

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Eighth Patient Name

First Name*

Middle Name

Last Name*
Eighth Patient Date of Birth*
Eighth Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)

Cardiovascular
Chest pain/shortness of breath
Blood pressure problem
Heart murmur
Heart valve problem
Taking heart medications
Pacemaker
Blood Related
Easy bruising
Frequent nosebleeds
Abnormal bleeding
Blood disease
Anemia
Allergies
Hay fever
Sinus problems
Taking allergy medications
Asthma
Digestive
Ulcers
Weight gain/loss
Special diet
Constipation/diarrhea
Kidney or bladder problems
Musculoskeletal System
Arthritis
Back or neck pain
Joint replacement
Other
Fainting spells, seizures, or epilepsy
Stroke
Heart attack
Frequent/severe headaches
Thyroid problems
Persistent cough
Swollen glands
Cancer/tumor
Diabetes
Tuberculosis/respiratory disease
Hepatitis, jaundice, or liver problems
Herpes
Other STDs
HIV/AIDS
Neurological disease
History of head injury
Anxiety
Known Allergic Reactions *
Local anesthetics
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin, Acetaminophen, or Ibuprofen
Codeine, Demerol, or other narcotics
Reaction to metals
Latex or rubber dam
Fluoride
No known drug allergies
Women Only
Contraceptives/hormones
Pregnant
Nursing
Menopause
HPV exposure
Are you currently taking any anticoagulants or blood thinners?*
No
Yes

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Ninth Patient Name

First Name*

Middle Name

Last Name*
Ninth Patient Date of Birth*
Ninth Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)

Cardiovascular
Chest pain/shortness of breath
Blood pressure problem
Heart murmur
Heart valve problem
Taking heart medications
Pacemaker
Blood Related
Easy bruising
Frequent nosebleeds
Abnormal bleeding
Blood disease
Anemia
Allergies
Hay fever
Sinus problems
Taking allergy medications
Asthma
Digestive
Ulcers
Weight gain/loss
Special diet
Constipation/diarrhea
Kidney or bladder problems
Musculoskeletal System
Arthritis
Back or neck pain
Joint replacement
Other
Fainting spells, seizures, or epilepsy
Stroke
Heart attack
Frequent/severe headaches
Thyroid problems
Persistent cough
Swollen glands
Cancer/tumor
Diabetes
Tuberculosis/respiratory disease
Hepatitis, jaundice, or liver problems
Herpes
Other STDs
HIV/AIDS
Neurological disease
History of head injury
Anxiety
Known Allergic Reactions *
Local anesthetics
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin, Acetaminophen, or Ibuprofen
Codeine, Demerol, or other narcotics
Reaction to metals
Latex or rubber dam
Fluoride
No known drug allergies
Women Only
Contraceptives/hormones
Pregnant
Nursing
Menopause
HPV exposure
Are you currently taking any anticoagulants or blood thinners?*
No
Yes

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Tenth Patient Name

First Name*

Middle Name

Last Name*
Tenth Patient Date of Birth*
Tenth Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)

Cardiovascular
Chest pain/shortness of breath
Blood pressure problem
Heart murmur
Heart valve problem
Taking heart medications
Pacemaker
Blood Related
Easy bruising
Frequent nosebleeds
Abnormal bleeding
Blood disease
Anemia
Allergies
Hay fever
Sinus problems
Taking allergy medications
Asthma
Digestive
Ulcers
Weight gain/loss
Special diet
Constipation/diarrhea
Kidney or bladder problems
Musculoskeletal System
Arthritis
Back or neck pain
Joint replacement
Other
Fainting spells, seizures, or epilepsy
Stroke
Heart attack
Frequent/severe headaches
Thyroid problems
Persistent cough
Swollen glands
Cancer/tumor
Diabetes
Tuberculosis/respiratory disease
Hepatitis, jaundice, or liver problems
Herpes
Other STDs
HIV/AIDS
Neurological disease
History of head injury
Anxiety
Known Allergic Reactions *
Local anesthetics
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin, Acetaminophen, or Ibuprofen
Codeine, Demerol, or other narcotics
Reaction to metals
Latex or rubber dam
Fluoride
No known drug allergies
Women Only
Contraceptives/hormones
Pregnant
Nursing
Menopause
HPV exposure
Are you currently taking any anticoagulants or blood thinners?*
No
Yes

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Parent or Guardian's Email Address

Email
Check to receive dental insights, patient offers, and exclusive discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Insurance Information

Dental Insurance Provider *

Insurance Provider Participant ID # *

Secondary Insurance Provider

Secondary Insurance Provider Participant ID #
Credit card on file (optional)

Card Number

Full Name

Expiration Date

Security Code

Zip Code
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)

Cardiovascular
Chest pain/shortness of breath
Blood pressure problem
Heart murmur
Heart valve problem
Taking heart medications
Pacemaker
Blood Related
Easy bruising
Frequent nosebleeds
Abnormal bleeding
Blood disease
Anemia
Allergies
Hay fever
Sinus problems
Taking allergy medications
Asthma
Digestive
Ulcers
Weight gain/loss
Special diet
Constipation/diarrhea
Kidney or bladder problems
Musculoskeletal System
Arthritis
Back or neck pain
Joint replacement
Other
Fainting spells, seizures, or epilepsy
Stroke
Heart attack
Frequent/severe headaches
Thyroid problems
Persistent cough
Swollen glands
Cancer/tumor
Diabetes
Tuberculosis/respiratory disease
Hepatitis, jaundice, or liver problems
Herpes
Other STDs
HIV/AIDS
Neurological disease
History of head injury
Anxiety
Known Allergic Reactions *
Local anesthetics
Penicillin or other antibiotics
Sulfa drugs
Barbiturates, sedatives, or sleeping pills
Aspirin, Acetaminophen, or Ibuprofen
Codeine, Demerol, or other narcotics
Reaction to metals
Latex or rubber dam
Fluoride
No known drug allergies
Women Only
Contraceptives/hormones
Pregnant
Nursing
Menopause
HPV exposure
Are you currently taking any anticoagulants or blood thinners?*
No
Yes

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


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