Patient Information

First Name

Last Name

Initial

Birthday

Social Security #

Address

Street

City

State

ZIP

Cell Phone

Work Phone

Home Phone

Who may we thank for referring you to us?

Emergency contact:

Phone

Relationship

Primary Insurance

Insured Name

Soc Sec#

Birthdate

Insurance Company

Subscriber ID

Group #

Phone

Main Subscriber (Self or Spouse) #ID

Name

Phone

Soc Sec#

Birthdate

Secondary Insurance

Insured Name

Soc Sec#

Birthdate

Insurance Company

Subscriber ID

Group #

Phone

Main Subscriber (Self or Spouse) #ID

Name

Phone

Soc Sec#

Birthdate

Patient's or Guardian's Signature

Date

X-RAY CONSENT FORM

Patient Name

Date

During your examination, the doctor may feel that X-rays/pictures will be needed in order to diagnose your condition. We would like to make you aware that X-rays may be required in order to administer treatment. In order to perform x-rays /pictures on any patient our office requires the patient's consent for such tests to be performed.

Please Choose One:

I understand that my condition may require my doctor to take X-rays to diagnose my symptoms.

I choose not to have X-rays at this time and release my doctor of all liabilities.

Please be advised X-rays and records request will have a charge of $50

Please allow 48 hours to process your request

Signature

Date

Females Only:

I understand that if I am pregnant and have X-rays taken which expose my lower torso to radiation, it is possible to injure the fetus. I have been advised that ten (10 days) following onset of a menstrual period are generally considered to be safe for X-rays exams. With those factors in mind, I am advising my doctor that:

I am pregnant

Yes

I don't know if I could be pregnant

Yes

Signature

Date

HIPAA Compliance Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient's rights section describing your rights under the law.

You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you.

However, such a revocation will not be retroactive.

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The practice reserves the right to change the privacy policy as allowed by law.
The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.

May we phone, email, or send a text to you to confirm appointments?

Yes

May we leave a message on your answering machine at home or on your cell phone?

Yes

May we discuss your medical condition with any member of your family?

Yes

If YES, please name the members allowed

This consent was signed by (PRINT NAME PLEASE)

Date

Signature

Date

Witness

Date

OFFICE POLICY FOR TREATMENT CANCELLATION

OFFICE CANCELLATION POLICIES We understand that you may occasionally need to cancel or reschedule your appointment. However, late arrivals, no-shows, and failure to cancel or reschedule your appointment during business hours twos days prior negatively impacts our ability to provide our other patients with the services they require. To help alleviate these situations, we have implemented the following policies:

OFFICE APPOINTMENT - CANCELLATION/RESCHEDULE POLICY We kindly request that you contact us during regular business hours two days before, to cancel or reschedule your office appointment, otherwise a $50 fee will be charged. (Monday appointments must be cancelled/rescheduled by the close of business on the previous Friday.)

OFFICE APPOINTMENT - NO-SHOW POLICY If you fail to show for a previously scheduled appointment, a $50 fee will be charged on the account and you will need to take care of payment before rescheduling.

SURGICAL/ SEDATION APPOINTMENT – CANCELLATION/RESCHEDULE POLICY We kindly request that you give us a minimum of 48 hours’ notice to cancel or reschedule your surgical/sedation appointment, otherwise a $150 fee will be charged. (Monday appointments must be cancelled/rescheduled by the previous Friday.)

SURGICAL/ SEDATION APPOINTMENT - NO-SHOW POLICY If you fail to show for a previously scheduled appointment, a $150 fee will be charged. Thank you. We appreciate your understanding and cooperation.

Print Name

Signature

Date

Medical History

Patient Name

Nickname

Age

Name of Physician/and their specialty

Most recent physical examination

Purpose

What is your estimate of your general health?

Excellent

Good

Fair

Poor

S.No.	DO YOU HAVE or HAVE YOU EVER HAD:	Yes	No
01.	Hospitalization for illness or injury
02.	an allergic or bad reaction to any of the following: aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline sulfa local anesthetic fluoride chlorhexidine (CHX) iodine metals latex nuts fruit milk red dye other
03.	heart problems
04.	a history of infective endocarditis
05.	an artificial heart valve
06.	a pacemaker
07.	an orthopedic soft tissue implant
08.	a heart murmur
09.	blood pressure
10.	a stroke
11.	anemia
12.	prolonged bleeding
13.	pneumonia
14.	chronic ear infections
15.	breathing problems
16.	sleep problems
17.	kidney disease
18.	liver disease
19.	vertigo
20.	thyroid
21.	diabetes
22.	arthritis
23.	cancer
24.	radiation therapy
25.	chemotherapy
26.	HIV/AIDS
27.	hepatitis
28.	tuberculosis
29.	sexually transmitted disease
30.	chronic pain
31.	a smoker, smoked previously or other (e.g., smokeless tobacco, vaping, e-cigarettes, and cannabis)
32.	considered a touchy/sensitive person
33.	often unhappy or depressed
34.	taking birth control pills
35.	currently pregnant
36.	diagnosed with a prostate disorder
37.	osteoporosis
38.	osteopenia
39.	bisphosphonate therapy
40.	denosumab therapy
41.	teriparatide therapy
42.	abaloparatide therapy
43.	romosozumab therapy
44.	glaucoma
45.	cataracts
46.	macular degeneration
47.	retinal detachment
48.	diabetic retinopathy
49.	hypertensive retinopathy
50.	optic nerve atrophy
51.	optic neuritis
52.	retinitis pigmentosa
53.	Stargardt disease
54.	Usher syndrome
55.	Leber congenital amaurosis
56.	achromatopsia
57.	cone-rod dystrophy
58.	other eye conditions

Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections)

List all medications, supplements, vitamins, and/or probiotics taken within the last two years.

Drug

Purpose

Drug

Purpose

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

Patient's Signature

Date

Doctor's Signature

Date