Patient Registration

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1 13925 Coalfield Commons Place Midlothian, VA Ph Fax Patient Registration Welcome to our office. We appreciate the confidence you place with us to provide dental services. The information provided on this form is important to your dental health and treatment plan. If there have been any changes in your health, please inform us. If you have any questions, don t hesitate to ask. Patient information ame (First, Middle initial, Last): Address: City: State: ZIP: Home Phone: Work Phone: Cell Phone: Sex: Male Female Marital Status: Married Single Divorced Separated Widowed Birth date: SS: Driver s License: I prefer receiving correspondences by US Mail Emergency Contact & Relationship: Phone numbers: Responsible Party (Policy Holder for Patient Primary Insurance if different from above) ame (First, Middle initial, Last): Address: City: State: ZIP: Home Phone: Work Phone: Cell Phone: Sex: Male Female Marital Status: Married Single Divorced Separated Widowed Birth date: SS: Driver s License: I prefer receiving correspondences by US Mail Emergency Contact/Relationship: Phone number: Primary Insurance Information ame of Insured: Relationship to Insured: Insured SS: Insured Date of Birth: Employer: Phone: Insurance Company: Phone: Group #: Secondary Insurance Information ame of Insured: Relationship to Insured: Insured SS: Insured Date of Birth: Employer: Employer Phone: Insurance Company: Insurance Phone: Group #: Referral Information Whom may we thank for referring you to our practice? Patient Friend Relative Dental Office ellow Pages ewspaper Website School Work Facebook Other

2 Dental History Pt.ame: What is the reason for your visit today? Have you ever noticed swelling or tenderness on your face or neck? Date of last Dental Visit What was done at your last dental visit? Previous Dentist's ame : State/ Zip : Telephone : Please answer : Have you had problems with previous dental treatment? Are you apprehensive about dental treatment? How often do you brush? How often do you floss? Do you gag easily? Do you use water-pick or electric tooth brush? Do you wear dentures? If so, how long? Does food catch between your teeth? Do you have difficulty in chewing your food? Do you chew on only one side of your mouth? Do you avoid brushing any part of your mouth due to pain? Do your gums bleed easily? Do your gums bleed when you floss? Are your teeth sensitive with: Hot foods or liquids? Cold foods or liquids? Sours? Sweets? Do you take fluoride supplements? Are you dissatisfied with the appearance of your teeth? Do you prefer to save your teeth? Do you or have you had orthodontic treatment (braces)? Does your jaw make noise? Do you clench or grind your jaws frequently? Do your jaws ever feel tired? Does your jaw get stuck so that you can t open freely? Does it hurt when you chew or open wide to take a bite? Do you have any jaw symptoms or headaches upon awaking in the morning? Do you have a temporomandibular (jaw) disorder (TMD)? Do you have pain in the face, cheeks, jaws, joints, throat, or temples? Are you unable to open your mouth as far as you want? Are you aware of an uncomfortable bite? Have you had a blow to the jaw (trauma)? Do you snore or have any other sleeping disorders? Do you feel that your mouth is dry? Do your gums or anywhere in the mouth feel swollen or tender? Have you ever noticed slow- healing sores in or about your mouth? Do you have too much saliva? Describe if there anything else that you would like to tell us. Medical History Pt. ame: Do you have, or have you had any of the following? Do you drink alcohol? If so, how much/often? Do you smoke? If so, how much/often? Heart Problems Chest pain Shortness of breath Blood pressure problem Heart murmur Heart valve problem Rheumatic fever Pacemaker Artificial heart valve Blood Problems Easy bruising Frequent nosebleeds Abnormal bleeding Blood disease (anemia) Ever require a blood transfusion? Taking heart medication

3 Allergy Problems Hay fever Sinus problems Skin rashes Asthma Epilepsy or other neurological disease? History of alcohol or drug abuse? Describe if you have any disease, condition, or problem not listed previously that you feel we should know about: Intestinal Problems Ulcers Weight gain or loss Special diet Constipation/Diarrhea Kidney or bladder problems Bone or Joint Problems Arthritis Back or neck pain Joint replacement (e.g., total hip, pins, or implants) Fainting Spells, Seizures Stroke(s) Frequent or severe headaches Are you allergic to any of the following? Local anesthetics ( ovocaine ) 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 Other allergy-please describe: Thyroid problems Persistent cough or swollen glands Premedications required by physician Do you take any medication? Cancer/Tumor Diabetes Urinate more than 6 times a day Thirsty or mouth is dry much of the time Family history of diabetes Tuberculosis or other respiratory disease Hepatitis, jaundice, or liver trouble Women Are you taking contraceptives or other hormonereplacement? Herpes or other STD HIV-positive/AIDS Are you pregnant? If so, expected delivery date: Are you nursing? Glaucoma Do you wear contact lenses? Have you reached menopause? If so, do you have any symptoms? History of head injury? To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient s) health. It is my responsibility to inform the dental office of my changes in medical status. Patient/Parent Signature: Date: Patient/Parent ame: Dentist Initial:

4 13925 Coalfield Commons Place Midlothian, VA Ph Fax OTICE OF PRIVAC PRACTICES Dear Patient: It is our desire to inform you that we are taking the new Federal (HIPAA-Health Insurance Portability and Accountability Act) laws written to protect the confidentiality of your health information seriously. We are required by law to maintain the privacy of your health information and provide you a description of our privacy practices. We will abide by the terms of this notice. Please review the document carefully. HOW OUR HEALTH IFORMATIO MA BE USED AD DISCLOSED AD HOW OU CA GET ACCESS TO THIS IFORMATIO For Treatment We will use your Health Information within our office to provide you with the best orthodontic care possible. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between orthodontic assistants, orthodontist, and business office staff. In addition, we may share your health information with physicians, referring dentists, clinical and dental laboratories, and other health care personnel providing you treatment. For Payment We may include your health information with an invoice used to collect payment for treatment you receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically. We will make every attempt to only work with companies with a similar commitment to the security of your health information. For Health Care Operations our health information may be used during performance evaluations of our staff. As a result, health information may be included in training programs for students, interns, associates, and business and clinical employees. It is also possible that health information will be disclosed during audits by insurance companies or government appointed agencies as part of their quality assurance and compliance reviews. our health information may be reviewed during the routine processes of certification, licensing or credentialing activities. In Patient Reminders Because we believe regular visits are very important to your overall treatment, we will remind you that it is time to make an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may be of interest to you or your family. They may include postcards, letters, and telephone calls. Abuse or eglect We will notify government authorities if we believe a patient is the victim of abuse, neglect, or domestic violence. We will make this disclosure only when we are compelled by our ethical judgment, when we believe we are specifically required or authorized by law or with the patient s agreement. Public Health and ational Security We may be required to disclose to Federal officials or military authorities health information necessary to complete an investigation related to public health or national security. Health information could be important when the government believes that the public safety could benefit when the information could lead to the control or prevention of an epidemic or the understanding of new side effects of a drug treatment or medical device. For Law Enforcement As permitted or required by State or Federal law, we may disclose your health information to a law enforcement official for certain limited circumstances, if you are a victim of a crime or in order to report a crime.

5 Family, Friends and Caregivers We may share your health information with those you tell us will be helping you with your home hygiene, treatment, medications, or payment. In case of an emergency, where you are unable to tell us what you want we will use our best judgment when sharing your health information only when it will be important to those participating in providing your care. Authorization to Use or Disclose Health Information Other than is stated above or where Federal, State or Local Law requires us, we will not disclose your health information other than with your written permission. ou may revoke that authorization in writing at any time. PATIET RIGHTS Restrictions ou have the right to request restrictions on certain uses and disclosures of your health information. Our office will make every effort to honor reasonable requests from our patients. Confidential Communications ou have the right to request that we communicate with you in a certain way. ou may request that we only communicate your health information privately with no other family members present or through mailed communication that is sealed. We will make every effort to honor your reasonable request for confidential communications. Inspect and Copy our Health Information ou have the right to read, review, and copy your health information, including your complete chart, x-rays, and billing records. If you would like a copy of your health information, please let us know. We may charge you a reasonable fee to duplicate and assemble your copy. Amend our Health Information ou have the right to ask us to update or modify your records if you believe your health information records are incorrect or incomplete. ou have the right to request an amendment for as long as our office maintains this information. In order to standardize our process, please provide us with your request in writing and describe your reason for the change. our request may be denied if the health information record in question was not created by our office, is not part of our records or if the records containing your health information are determined to be accurate and complete. Documentation of Health Information ou have the right to ask us for a description of how and where your health information was used by our office for any reason other than for treatment, payment, or health operations. Please let us know in writing the time period for which you are interested. Thank ou for limiting your request to no more than 2 years at a time. We may charge you a reasonable fee for your request. Request a Paper Copy of this otice - ou have the right to obtain a copy of this otice of Privacy Practices directly from our office at any time. Stop by our office to pick one up, visit our website: or call and we will mail a copy to you. - We are required by law to maintain the privacy of your health information and to provide to you and your representative this otice of our Privacy Practices. - We are required to practice the policies and procedures described in this notice but we do reserve the right to change the terms of our otice. If we change our privacy practices we will be sure all of our patients receive a copy of the revised otice. - ou have the right to express complaints to us or to the Secretary of Health and Human Services if you believe your privacy rights have been compromised. We encourage you to express any concerns you may have regarding the privacy of your information. Please let us know of your concerns or complaints in writing. Change to This otice We reserve the right to change this notice and the revised or changed notice will be effective for information we already have about you as well as any information we receive in the future. The current notice will be posted in the facility and on our website and include the effective date. In addition, each time you register at or are admitted to the facility for treatment or health care services as an inpatient or outpatient, we will offer you a copy of the current notice in effect. Complaints If you believe your privacy rights have been violated, you may file a complaint with the facility by following the process outlined in the facility s Patient Rights documentation. ou may also file a complaint with the Secretary of the

6 Department of Health and Human Services. All complaints must be submitted in writing. ou will not be penalized for filing a complaint. Other Uses of Health Information Other uses and disclosures of health information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose health information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, we will no longer use or disclose health information about you for the reasons covered by your written authorization. ou understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you. Apple Tree Dentistry Privacy Office Coalfield Commons Place Midlothian, VA Ph Fax For more Information about HIPAA or to file a complaint: The U.S. Department of Health & Human Services Office of Civil Rights 200 Independence Avenue, S.W. Washington, D.C (toll-free)

7 13925 Coalfield Commons Place Midlothian, VA Ph Fax Receipt of otice of Privacy Practices I,, have received a copy of Apple Tree Dentistry, PLLC s otice of Privacy Practices. Patient Signature: Date: Witness Signature: Date: I authorize you to release my personal health information to and/or discuss with the following Individual(s): Please print: Relationship: Please print: Relationship: Please print: Relationship:

8 13925 Coalfield Commons Place Midlothian, VA Phone Fax FIACIAL POLIC Thank you for choosing Apple Tree Dentistry as your health care need. Our goal is to provide the highest quality of dental care possible and to have clear communication of our financial policy. It is required to read and sign on the financial policy prior to the treatment. ALL ACCOUTS ARE DUE AD PAABLE AT THE TIME OF SERVICE. If a procedure requires multiple appointments, payment is required in full at the first appointment. We accept major credit cards or CareCredit TM Patient with insurance: The PATIET is responsible for the ESTIMATED non-covered portion, procedure, deductible and/or copay at the time of the service. Parents accompanying their children are financially responsible for payment, and parents not accompanying their child to an appointment must make PRIOR arrangements for payment. Any remaining balance will be subject to an annual interest rate of 18% if a balance has not been paid within thirty (30) days. In addition, an administrative fee of $25 will be charged if a balance has not been paid within 30 days. Records can be viewed at any time. There is a nominal charge for release or copies of records. Because instruments, chairs, and personnel are reserved exclusively for your appointment, there is a $50 CHARGE FOR MISSED APPOITMET LESS THA 48-HOUR OTICE I ADVACE. If the appointment was scheduled less than 48 hours of the date of appointment, 24-hour notice is required for cancellation not to have a missed appointment charge. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid in full at the time services. Thank you for understanding our Financial Policy. Please let us know if you have questions or concerns. I,, have read, understand, and agree to this Financial Policy and agree to these financial terms. Signature Date Patient or responsible party

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