New Patient Information Personal Information Mr. Mrs. Ms. Miss (Last) (First) (MI) What name shall we call you? Date of Birth Sex Male Female Home address City State Zip E-mail Address Home # Cell # Employer Occupation Spouse Name Children(s) names Parent /guardian name if minor Emergency contact Relation Telephone Who may we thank for referring you? Are you a full-time college student? Name of school and city: Insurance Information Name of Insurance Subscribers Name DOB ID # Group # Phone# of Insurance Employer Name HEALTH/DENTAL INFORMATION DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING? CHECK YES OR NO Yes No Yes No Yes No LOW BLOOD SUGAR CANCER DIGESTIVE PROBLEMS DIABETES LATEX ALLERGY EATING DISORDERS HAY FEVER, ALLERGIES HIV POSITIVE ARE YOU PREGNANT ASTHMA AIDS RHEUMATIC FEVER CIRCULATORY PROBLEM SPINAL FUSION MITRAL VALVE PROLAPSE HEPATITIS A ARTIFICIAL JOINTS HEART DISEASE HEPATITIS B OSTEOPOROSIS HEART ATTACK HEPATITIS C SINUS PROBLEMS HEART PACE MAKER JAUNDICE ANEMIA HEART SURGERY LUNG PROBLEMS BLOOD DISORDER STROKE TUBERCULOSIS EXCESSIVE BLEEDING HIGH BLOOD PRESSURE EPILEPSY / SEIZURE FAINTING / BLACKOUTS LOW BLOOD PRESSURE BLOOD TRANSFUSION NERVOUS DISORDER HEART VALVE REPLACEMENT FACIAL / HEAD INJURY HEADACHES / MIGRAINES SEVERE SPINAL STENOSIS RADIATION KIDNEY PROBLEMS THYROID PROBLEMS CHEMOTHERAPY GLAUCOMA / EYE ISSUE HIGH CHOLESTEROL MALIGNANCIES ULCERS DO YOU HAVE ANY OTHER DISEASES OR CONDITIONS NOT LISTED ABOVE? IF YES PLEASE LIST: DO YOU HAVE ALLERGIES TO ANY OF THE FOLLOWING? PLEASE CHECK ALL THAT APPLY ASPIRIN CODEINE ANESTHETICS XYLOCAINE NOVOCAINE LIDOCAINE SEDATIVES SULFA PENICILLIN ERYTHROMYCIN OTHER: LIST ALL MEDICATIONS CURRENTLY BEING TAKEN OR A PRINTED COPY OF YOUR LIST: NAME AND PHONE # OF PHYSICIAN: HAVE YOU BEEN HOSPITALIZED IN THE LAST YEAR? IF YES, EXPLAIN DO YOU CONSUME ALCOHOL OR USE TOBACCO? Yes No IN WHAT QUANTITIES HAVE YOU EVER BEEN TREATED BY A PERIODONTIST, ORTHODONTIST OR ENDODONTIST? Yes No IF YES, EXPLAIN ARE YOU HAPPY WITH THE APPEARANCE OF YOUR TEETH? Yes No REASON FOR THIS DENTAL VISIT: DATE OF YOUR LAST DENTAL CLEANING WAS YOUR LAST DENTAL CLEANING AT THIS OFFICE? Yes No HAVE YOU NOTICED ANY OF THE FOLLOWING? Yes No Yes No DISCOMFORT IN FACE, HEAD, NECK, JAW JAW CLICKING OR POPPING LOOSE TEETH SWELLING OR LUMPS IN MOUTH FOOD CAUGHT BETWEEN TEETH BLEEDING OR SORE GUMS SENSITIVITY TO SWEETS, HOT OR COLD RECURRING SORE IN OR AROUND MOUTH TEETH TENDER TO CHEWING To avoid any misunderstanding concerning your dental insurance, we wish for our patients to know that all professional services rendered will be out of network and charged directly to the patient who is responsible for the payment of said services. We do not render serviceor treatment on the basis that the insurance company will pay our fees unless a pre-determination of benefits has been established in writing. However, we will file the necessary insurance forms for all treatment and services that have been completed. Payment is due when the service is rendered unless other arrangements have been made. If you must change a scheduled appointment, please inform the office within 24 hours of your scheduled appointment to avoid acharge to your account. I hereby authorize Chase Hall, DMD to take radiographic X-rays, study models, photographs or any other diagnostic aid deemed necessary to make a thorough diagnosis for my dental care. I also authorize the doctor to prescribe necessary forms of medication, and to perform any treatment that may be indicated and agreed upon regarding my dental care. I understand my rights to privacy regarding my protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to provide and coordinate my treatment among consulting health/dental care providers who may be involved in that treatment directly and indirectly. I further authorize the release of any information regarding the diagnosis and records of treatment to my insurance company. The release of such information to the insurance company is solely for the purpose of facilitating the billing and reimbursement of treatment directly to the dentist for insurance benefits under which I am entitled. I understand the responsibility for payment of services rendered for myself and my family are due and payable at the time the services are performed. Under the requirements for HIPAA we are not allowed to give your protected health information to anyone without your consent. If you wish to have a family member or someone close to you have access to your private health information, please indicate below. You May Disclose My Information To The Following Do Not Disclose My Information To Anyone But Me 1 Relationship to Patient: Date 2 Relationship to Patient: Date MY SIGNATURE CONFIRMS THAT I UNDERSTAND ALL HIPAA AND FINANCIAL POLICIES AS OUTLINED ABOVE AND THAT THE HEALTH AND DENTAL INFORMATION THAT I HAVE PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE. PATIENT NAME Date SIGNATURE OF PATIENT OR RESPONSIBLE PARTY: Please enter code above in the field below.