DENTISTRY PATIENT REGISTRATION. Last Name: Preferred Name: Address 2: Ext: O Primary Insurance Policy Holder O Secondary Insurance Policy Holder.

Transcription

1 a LAKE E LST'NCRE DENTISTRY PATIENT REGISTRATION ID: First Name: Patient ls: I j Policy Holder! Responsible Party Chart ld: -- Responsible Party (if someone other than the patient) First Name: Last Name: Preferred Name: Last Name: Middle Initial: Middle Initial: City, State, Zip: Pager: Home Phone: Work Phone: Ext: Cellular: Birth Date: Soc Sec: Drivers Lic: O Responsible Party is also a Policy Holder for Patient Patient Information i City: Home Phone: Sex: I Uate Birth Date: Section 2 Employmenl Status: Q student status: Q Medicaid ld: Full Time Q Female Full time Work Phone: Age: O Primary Insurance Policy Holder O Secondary Insurance Policy Holder State / Zip: Marital Status: Q nianieo Soc. Sec: Q Part time Q Retired Q Part Time Pref. Dentist: Ext: Q single Pager: Cellular: Q Divorced Q Separated Q Widoweo Drivers Lic:! would like to receive conespondences via . Section 3 Additional Comments: I Employer ld: Canier ld: Pref, Pharmacy Pref. Hyg.: -Primary Insurance Information Name of Insured: Relationship to InsuredQ Se f Q spouse Q cito Q otner i lnsured Soc. Sec: lnsured Birth Date: ' Employer: Ins. Company: I, City,State,Zip: Rem. Benefits:.00 Rem. Deduct: 00 Secondary Insurance Information Name of Insured: City,State,Zip: Relationship to InsuredQ Sef Q spouse O child Q oter lnsured Soc. Sec: lnsured Birth Date: Employer: City,State,Zip: I Rem. Benefits:.00 Rem. Deduct: 00 Ins. Company: City,State,Zip: _

2 LAKE ELSfuCRE DENTISTRY MEDICAL HISTORY PATIENT NAME Birth Date Although dental personnel primarily eat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may I have, or medication that you may be taking, could have an important intenelationship with the dentisy you will receive. Thank you for answering the l following questions. Are you under a physician's care now? Q Ves Q tto Have you ever been hospitalized or had a major operation? Q Ves Q No Have you ever had a serious head or neck injury? Q Ves Q tto Are you taking any medications, pills, or drugsz Q Yes Q ruo Do you take, or have you taken, Phen-Fen or Redux? Q Ves Q tto Haveyou everlaken Fosamax, Boniva, Actonel orany^ r, r, other medications containing bisphosphonates;'\, Yes L) No Are you on a special diet? Q ves Q No Do you use tobacco? Q Ves Q ruo Do you use conolled substances? Q ves Q ruo -Are you allergic to any of the following?-**** I Aspirin -] Penicillin! codeine! Local Anesthetics I Acrylic [ 1 Other! n,tetat! Latex Sulfa druqs I l I i i Do you have, or have you had, any of the following? AIDS/HIV Positive Q Ves Q Ho Alzheime/s Disease Q Ves Q tto Anaphylaxis QvesQno Anemia Angina Arthritis/Gout QvesQwo Artificial Heart Valve Q ves Q ruo Artilicial Joint Q ves Q Asthma No Blood Disease Q ves Q ruo Blood Transfusion Q ves Q ruo Breathing Problem Q ves Q No Bruise Easily Q ves Q tto Cancer QvesQNo Chemotherapy QvesQNo Chest Pains QvesQNo Comments: Cortisone Medicine Q ves Q Diabetes t'to QvesQno Drug Addiction Q ves Q tlo Easilywinded QVesQtto Emph)rsema QvesQlo Epilepsy or Seizures Q Ves Q No Excessive Bleeding Q ves Q No ExcessiveThirst Q VesQ uo Fainting Spells/UzzinessQ Yes Q No FrequentCough Frequent Dianhea Q ves Q tlo Frequent Headaches Q Ves Q No Genital Herpes Q ves Q tto Glaucoma Q ves Q tto Hay Fever Q ves Q tto Heart Attack/Failure Q Ves Q Ho Hearl Murmur Q ves Q tto HeartPacemaker Q vesq tto HeartTrouble/Disease Q Yes Q No not listed above? Q Yes Q No Hemophilia QVesQr.to HepatitisA Q Ves Q tto HepatitisBorC Q Ves Q tto Herpes High Blood Pressure Q ves Q No High Cholesterol Q Ves Q ruo HivesorRash Hypoglycemia InegularHeartbeat Q YesQ Ho Kidney Problems Q Ves Q Leukemia ruo QvesQtlo LiverDisease Low Blood Pressure Q ves Q tto Lung Disease Q ves Q ruo Mial ValveProlapseQ Yes Q osleoporosis No Pain in Jaw Joints Q Ves Q No Parathyroid Disease Q Yes Q No PsychiaicCare Q vesq ruo Radiation Treatmenls Q Ves Q ruo Recent Weight Loss Yes Q ruo Renal Dialysis Q Ves Q RheumaticFever t'to QvesQno Rheumatism Q ves Q tto Scadet Fever Q ves Q tto Shingles Q ves Q tto Sickle Cell Disease Sinus Trouble Spina Bifida Q ves Q tto Stomach/lntestinal oisease Q ves Q ruo Soke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or GroMhs Ulcers Venereal Disease Yellow Jaundice QvesQtto QvesQNo QvesQro 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. lt is my responsibility to inform the dental office of any changes in medical status. SIGNATURE OF PATIENT, PARENT, or GUARDIAN DATE

3 Lake Elsinore Dentisy Ganyon Drive Suite 201 Lake Elsinore, CA PLEASE PRINT CLEARLY Patient Name Address City, State ZIP Phone Today's Date Date of Birth Fax I, hereby authorize Lake Elsinore Dentisy to release, use and/or disclose my protected health information as directed below. This Authorization pertains to the following types of protected health information about me: All dental records received or created by [Lake Elsinore Dentisy Dental report(s) (please specify) Dental image(s) (please specify) All dental records relating to (specify injury or condition) Other (please describe) Please release my health information to: Organization Contact Address City, State ZIP Phone Fax Handling Notes I understand that, per my voluntary request, this Authorization permits Lake Elsinore Dentisy to release, use or disclose my protected health information for purposes other than payment, eatment, or healthcare operations as defined in the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and its corresponding regulations. I further understand that I may revoke this Authorization at any time by providing written notification to Lake Elsinore Dentisy. Revocation of this Authorization will be effective on the date notice is received and processed by Lake Elsinore Dentisy except to the extent that action has alreadv been taken in reliance upon this Authorization. This Authorization will expire one (1) year from the date that I sign it, unless I indicate an alternative exoiration date below: Enter Alternative Expiration Date: 20

4 AUTHORIZATION FOR THE RELEASE OF PROTECTED HEALTH INFORMATION Lake Elsinore Dentisy Canyon Estates Drive Suite 201 Lake Elsinore. CA Your decision to sign this Authorization is voluntary. Lake Elsinore Dentisy will not refuse eatment to you if you refuse to sign this Authorization. When your protected health information is released as provided by this Authorization, please be aware that the named recipient (above) may not be legally obligated (under HIPAA) to obtain an authorization for subsequent re-disclosure of your protected health information. I have read the contents of this Authorization, and I confirm that the contents are consistent with my directions. I understand that by signing this Authorization, I am permitting Lake Elsinore Dentisy to release, use or disclose my protected health informatton. Signature Date Print Name Witness (Optional) I affirm that I am the personal representative of the patient noted above and that I have the authority to authorize the release, use or disclosure of the patient's protected health information on his/her behalf. I have read the contents of this Authorization, and I confirm that the contents are consistent with my directions. I understand that by signing this form, I am authorizing, on behalf of the patient, the release, use or disclosure the patient's protected health information. Signature Date Parent Print Name Guardian Relationship to Patient Power of I FOR OFFICE USE ONLY

5 ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES Lake Elsinore Dentisy Canyon Drive Suite 201 Lake Elsinore, GA 92532