Patient s First Name: Last Name: Middle Initial: Preferred Name: Home Phone: Work Phone: Cell Phone: Street Address:
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1 Patient s First Name: Last Name: Middle Initial: Preferred Name: Hme Phne: Wrk Phne: Cell Phne: Street Address: City: State: Zip Cde: Patient s Sex: Ο Male Ο Female Marital Status: Ο Married Ο Single Ο Divrced Ο Separated Ο Widwed Birth Date: Age: Scial Security: Driver License: Emergency Cntact Persn: Emergency Cntact Phne: Referring Dentist/Physician/Persn: Is Patient the Ο Insurance Plicy Hlder Ο Respnsible Party Respnsible Party (if smene ther than the patient) Patients Relatinship t Respnsible Party: Ο Self Ο Spuse Ο Child Ο Other Respnsible Party s First Name: Last Name: Middle Initial: Respnsible Party s Street Address: City: State: Zip Cde: Ο Respnsible Party is als Plicy Hlder fr Patient Ο Primary Insurance Plicy Hlder Ο Secndary Insurance Plicy Hlder Primary Insurance Infrmatin Name f Insured: Patient s Relatinship t Insured: Ο Self Ο Spuse Ο Child Ο Other Insured Date f Birth: Infrmatin fund n Dental Insurance Card Emplyer: Grup Number: Insured Scial Security r Member ID number: Insurance Cmpany: Insurance Cmpany Address: City, State, and Zip Cde: Secndary Insurance Infrmatin Name f Insured: Patient s Relatinship t Insured: Ο Self Ο Spuse Ο Child Ο Other Insured Date f Birth: Infrmatin fund n Dental Insurance Card Emplyer: Grup Number: Insured Scial Security r Member ID number: Insurance Cmpany: Insurance Cmpany Address: City, State, and Zip Cde:
2 MEDICAL HISTORY PATIENT NAME Birth Date Althugh dental persnnel primarily treat the area in and arund yur muth, yur muth is a part f yur entire bdy. Health prblems that yu may have, r medicatin that yu may be taking, culd have an imprtant interrelatinship with the dentistry yu will receive. Thank yu fr answering the fllwing questins. Are yu under a physician's care nw? Yes N If yes, please explain: Have yu ever been hspitalized r had a majr peratin? Yes N If yes, please explain: Have yu ever had a serius head r neck injury? Yes N If yes, please explain: Are yu taking any medicatins, pills, r drugs? Yes N If yes, please explain: D yu take, r have yu ever taken, Phen-Fen r Redux? Yes N Are yu n a special diet? Yes N If yes, fr what reasn: D yu use tbacc? Yes N If yes, hw much: D yu use cntrlled substances? Yes N If yes, what d yu use: Wmen: Are yu Pregnant/Trying t get pregnant? Yes N Taking ral cntraceptives? Yes N Nursing? Yes N Are yu allergic t any f the fllwing? Aspirin Penicillin Cdeine Acrylic Metal Latex Lcal Anesthetics Other If ther, please explain: D yu have, r have yu had, any f the fllwing? AIDS/HIV Psitive Yes N Crtisne Medicine Yes N Hemphilia Yes N Renal Dialysis Yes N Alzheimer's Disease Yes N Diabetes Yes N Hepatitis A Yes N Rheumatic Fever Yes N Anaphylaxis Yes N Drug Addictin Yes N Hepatitis B r C Yes N Rheumatism Yes N Anemia Yes N Easily Winded Yes N Herpes Yes N Scarlet Fever Yes N Angina Yes N Emphysema Yes N High Bld Pressure Yes N Shingles Yes N Arthritis/Gut Yes N Epilepsy r Seizures Yes N Hives r Rash Yes N Sickle Cell Disease Yes N Artificial Heart Valve Yes N Excessive Bleeding Yes N Hypglycemia Yes N Sinus Truble Yes N Artificial Jint Yes N Excessive Thirst Yes N Irregular Heartbeat Yes N Spina Bifida Yes N Asthma Yes N Fainting Spells/Dizziness Yes N Kidney Prblems Yes N Stmach/Intestinal Disease Yes N Bld Disease Yes N Frequent Cugh Yes N Leukemia Yes N Strke Yes N Bld Transfusin Yes N Frequent Diarrhea Yes N Liver Disease Yes N Swelling f Limbs Yes N Breathing Prblem Yes N Frequent Headaches Yes N Lw Bld Pressure Yes N Thyrid Disease Yes N Bruise Easily Yes N Genital Herpes Yes N Lung Disease Yes N Tnsillitis Yes N Cancer Yes N Glaucma Yes N Mitral Valve Prlapse Yes N Tuberculsis Yes N Chemtherapy Yes N Hay Fever Yes N Pain in Jaw Jints Yes N Tumrs r Grwths Yes N Chest Pains Yes N Heart Attack/Failure Yes N Parathyrid Disease Yes N Ulcers Yes N Cld Sres/Fever Blisters Yes N Heart Murmur Yes N Psychiatric Care Yes N Venereal Disease Yes N Cngenital Heart Disrder Yes N Heart Pace Maker Yes N Radiatin Treatments Yes N Yellw Jaundice Yes N Cnvulsins Yes N Heart Truble/Disease Yes N Recent Weight Lss Yes N Have yu ever had any serius illness nt listed abve? Yes N If yes, please explain: Cmments: T the best f my knwledge, the questins n this frm have been accurately answered. I understand that prviding incrrect infrmatin can be dangerus t my (r patient's) health. It is my respnsibility t infrm the dental ffice f any changes in medical status. SIGNNATURE OF PATIENT, PARENT, r GUARDIAN DATE
3 Nrthwest Peridntics Stanley D. Halpern, D.D.S., P.C. Practice Limited t Peridntics & Implants 220 Heritage Walk, Suite 102 Wdstck, Gergia Office Fax Dental Health Infrmatin Reasn fr yur visit t ur ffice: Date f last dental visit: / / Date f last dental cleaning: / / Yes N Are yu in pain?... Are yu under unusual stress at hme/wrk?... Have yu had temprmandibular jint (TMJ) prblems befre? D yu clench r grind yur teeth?... D yur gums feel tender r swllen?.. D yur gums bleed while brushing r flssing? (circle ne r bth) D yu gag easily? D yu have an electric tth brush?... If yes, what name brand? Have yu ever been given Nitrus Oxide (laughing gas)? D yu like Nitrus Oxide? Are ur teeth sensitive t: (Circle all that apply) Cld Ht Sweet Sur D yu wear dentures upper/lwer r partials upper/lwer? (circle all that apply) Hw ften d yu brush yur teeth? Hw ften d yu flss yur teeth? What type f tthpaste d yu use? Texture f tthbrush yu use?
4 Practice Limited t Peridntics and Implants 220 Heritage Walk Suite 102 Wdstck, Ga Office:(770) Fax:(770) ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **Yu May Refuse t Sign This Acknwledgement** Date: I, (Please Print Name) have received a cpy f this ffice s Ntice f Privacy Practices. I authrize the release f medical/dental infrmatin. Including but nt limited t diagnsis, recrds, examinatin, r treatment rendered t me and/r claims/accunt infrmatin. This infrmatin may be released t: Please check and give name f all that apply [ ] Spuse: [ ]Parent: [ ]Child: [ ]Other: [ ] Or yu prefer yur infrmatin nt t be released t anyne. This release f medical/dental infrmatin will remain in effect until terminated by me in writing. Messages/Appintment Reminders Please call: [ ] Hme: [ ]Cell: If unable t reach me: [ ] Wrk: Ext: [ ] Yu may leave a detailed message [ ] Please leave a message asking me t return call [ ] Or The best time t reach me is (day & time) Signature f Patient/Patients Respnsible Party: Fr Office Use Only We attempted t btain written acknwledgement f receipt f ur Ntice f Privacy Practices, but acknwledgement culd nt be btained due t: Individual refused t sign Cmmunicatins barrier prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining acknwledgement
5 Practice Limited t Peridntics and Implants 220 Heritage Walk Suite 102 Wdstck, Ga Office:(770) Fax:(770) Office Plicies We are cmmitted t prviding yu with the best pssible care. We emphasize ur team s relatinship with yu and yur ptimal dental health. We are pleased t discuss ur prfessinal fees with yu at this time. Yur clear understanding f ur Financial Plicy is imprtant t ur prfessinal relatinship. Please ask if yu have any questins abut ur fees, financial plicy, r yur respnsibility. - All patients must cmplete ur PATIENT INFORMATION FORM befre seeing the dctr. - All applicable c-pays, persnal balances, bth current and prir are due at the time f service. - WE ACCEPT CASH, CHECKS, DISCOVER, VISA/MASTERCARD and AMERICAN EXPRESS Please circle yur payment chice fr tday s visit. REGARDING INSURANCE: If yu have insurance, we are happy t file yur insurance claim as a curtesy. We will submit yur insurance t reimburse yu fr yur first visit. We will accept insurance assignment if we have a written pre-determinatin frm yur insurance cmpany and will require yu t pay the difference at the time f service. If yu chse t have treatment dne befre a pre-determinatin has been received back frm insurance, yu will be respnsible fr 50% f the balance befre treatment. Late Payment Charges are added t unpaid accunts after 60 days frm date f service. If yur insurance cmpany pays mre than the balance due, we will send a refund check t yu in a timely manner. INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. Nt every dental service is a cvered benefit in all insurance plicies. Plicy limitatins vary frm cntract t cntract. Failure t prvide updated insurance infrmatin may result in denials, which the patient will be held respnsible. MISSED APPOINTMENTS: Unless cancelled at least 48 hurs in advance, it is ur plicy t charge $75.00 r 15% f the scheduled appintment fee, whichever is greater. This fee is nt cvered by insurance. After the first brken appintment, Nrthwest Peridntics reserves the right t require a depsit fr any future appintments payable at the time f scheduling. This depsit is nn-refundable if yu cancel appintment with less than 48 ntice. It will g tward c-pay when yu keep yur appintment. LATE ARRIVALS: Patients wh are 15 minutes late t their appintments will be asked t reschedule, r if the dctr s time allws will be wrked in arund ur ther patients. The Atlanta Area is very cngested with traffic and cnstructin, s please allw extra travel time. YOUR SIGNATURE IS REQUIRED FOR US TO: PROCESS ALL INSURANCE CLAIMS TO ENSURE PAYMENT FOR SERVICES RENDERED TO RELEASE MEDICAL INFORMATION TO INSURANCE COMPANIES TO RELEASE INFORMATION TO OTHER MEDICAL/DENTAL PROVIDERS, WHEN NECESSARY, FOR YOUR TREATMENT. TO RECEIVE INFORMATION FROM OTHER PROVIDERS AND INSURANCE COMPANYS TO FACILITATE YOUR TREATMENT I authrize the release f all medical infrmatin necessary t prcess my claims and I authrize the release f this same infrmatin, when necessary, t ther prviders rendering medical/dental care. I assign all medical surgical benefits, including majr medical t which I am entitled, t Stanley D. Halpern, D.D.S., P.C. This assignment will remain in effect until revked by me in writing. A phtcpy f this assignment is t be cnsidered as valid as the riginal. Patients Name: (Please Print) Tday s Date: Respnsible Party s Name: (Please Print) Respnsible Party s Signature: Witness Signature:
PATIENT REGISTRATION FORM
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