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Patient Information

Name*
Address*
Birthdate*
If patient is a minor, give parent's or guardian's name:
Spouse Name
Spouse Birthdate

Responsible Party / Billing Information (if someone other than the patient)

Responsible Party Name
Address
Birthdate
Spouse Name
Birthdate

Insurance Information

Insured's Name:
Birthdate
Address
Do you have dual coverage?

Medical History

Are you under a physician's care now?
Have you ever been hospitalized or had a major operation?
Are you taking any medications, pills or drugs?
Do you take, or have you taken, PhenFen or Redux?
Do you use tobacco?
Do you use controlled substances?
Pregnant/Trying to get pregnant?
Currently nursing?
Taking oral contraceptives?

Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic.)

Have you ever had any of the following? (Please check all that apply)

Have you ever been given antibiotics before dental treatment
Have you recently consumed alcohol?
Have you recently used recreational drugs?

Recreational use combined with local anesthesia may cause a life-threatening emergency.

Dental History

Have you avoided regular dental care?
Do you feel you have active decay?
Do you experience frequent bad breath?
Do you feel you have gum disease?
Have you ever had gum treatments?
Are you happy with the appearance of your teeth?
Would you like your teeth to be whiter?

Nearest Relative

Address

Authorizations and Acknowledgments

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES AND CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION


Notice of Private Practices: You have the right to read our Privacy Practices before you decide whether or not to sign this consent. A copy of our Notice and/or this consent is available upon request. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we make of your protected health information.


Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. I have been shown a copy of this office’s Notice of Privacy Practices and have had full opportunity to read and consider its contents. 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.


In addition to allowable disclosures described in the statement of Privacy practices, I hereby specifically authorize disclosure fo my Protected Healthcare information to the person(s) identified below. (I understand the default answer in "NO" without indicating "YES" in answer to each individual question personal protected information cannot be shared with anyone unles otherwise allowed by HIPAA rules.)

Spouse Only
Parents Only
Any member of the immediate family (parents, grandparents, siblings, others)
Other

By placing my name and date below, I acknowledge that I have read and understand the above policies. Should I have any questions, I can contact the practice at any time.

Name
Date

Email & SMS Communication Release

PATIENT E‐MAIL AND TEXT MESSAGING


Due to the changing world of healthcare and technology, we now have the ability to provide our patients with certain types of information via e‐mail and/or text messaging.


We believe strongly in protecting the privacy of our patients. When you provide this information to us, it is only used as a way to communicate with you. In order to protect your privacy, no confidential or personal information will be sent from us via email or text messaging. We do not share the names, e‐mail addresses, and/or telephone numbers of patients with any other companies, or with any other patient.


By placing my name and date below, I acknowledge that I have read and understand the above statement on emails and text messages. Should I have any questions, I can contact the practice at any time. I hereby give permission to send messages to me via email and/or text messaging as means of communication.

Name
Date
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