New Patient Form "*" indicates required fields PATIENT INFORMATIONName* First D.O.B* MM slash DD slash YYYY Social Security# Driver License # Address* Street Address City State / Province / Region ZIP / Postal Code Phone*Email* Marital Status* Single Married Child Gender* Male Female Emergency Contact* Relationship* Phone*Email* HEALTH INFORMATION (check all that apply)Do you have any of the following disease(s)? AIDS/ HIV Positive Alzheimer’s Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joints Asthma Blood Disease Blood Transfusion Breathing Problems Bruise Easily Cancer Chemo Therapy Chest Pains Congenital Heart Disorder Convulsions Cortisone Medication Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives/Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Disease Lung Disease Mitral Valve Prolapse Osteoporosis Pacemaker Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatment Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsilitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice Are you allergic to any of the following? Aspirin Metal Penicillin Latex Codeine Sulfa Drugs Acrylic Local Anesthetics Other? (please list) Are you now under the care of a physician?* Yes No If yes please explain* Name of Physician* Phone*Are you taking any medications (please list)? Have you been hospitalized or had a major operation?.* Yes No If yes, please explain* Have you ever had a serious head or neck injury?.* Yes No If yes, please explain* Are you taking any medications, pills, or drugs?.* Yes No If yes, please explain* Do you take, or have you taken, Phen-Fen or Redux?* Yes No If yes, please explain* Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?* Yes No If yes, please explain* Are you on a special diet?* Yes No If yes, please explain* Do you use tobacco?* Yes No If yes, please explain* Do you use controlled substances?.* Yes No If yes, please explain* Are you pregnant or trying to get pregnant?* Yes No Nursing?* Yes No On birth control?* Yes No Do you have any health problems that need further clarification?* Yes No If yes, please explain* DENTAL & COSMETIC INFORMATIONPrevious Dentist Date of Last Dental Visit MM slash DD slash YYYY Reason for this visit today Have you ever had any complications following dental treatment? Yes No If yes, please explain Is there anything about your smile that you do not like? Do you like the appearance of your teeth? Do you have any old fillings or dental treatment that you are unhappy with?* Yes No Is there anything else you would like us to know?* REFERRAL INFORMATIONWhom may we thank for referring you to our practice? Friend Another doctor Dental office School Work Other Name of person or office referring you to our practice RESPONSIBLE PARTY INFORMATIONName of Responsible Party* D.O.B* MM slash DD slash YYYY Relationship to Patient?* Self Spouse Parent Guardian EMPLOYMENT INFORMATIONEmployer Name Occupation Address Street Address City State / Province / Region ZIP / Postal Code INSURANCE INFORMATIONInsurance Name Telephone # Name of Insured First Middle Last Is the insured the patient?* Yes No Insured’s Birthdate* ID #* Group #* Insured’s Employer Name* Address* Street Address City State / Province / Region ZIP / Postal Code Patient’s Relationship to Insured?* Self Spouse Parent Guardian FINANCIAL AGREEMENTIn order to avoid any misunderstanding regarding our financial policy, it is necessary for you to read and sign this document before treatment. DENTAL INSURANCE: As a courtesy we will gladly file your claims provided you agree to the following: You must provide us with an insurance card and all the information necessary to verify your coverage and file your claim. Your insurance policy is a contract between you, your employer, and the insurance company. We are NOT a party to that contract. Although we may estimate your insurance benefits, we are not responsible for their accuracy. Receiving our services indicates your acceptance of responsibility to pay regardless of your estimate. All charges not paid by your insurance company are your responsibility regardless of the reason for nonpayment. If your insurance fails to pay within 60 days, you will be responsible for the balance on your account. Not all the services we provide are covered benefits. Benefits differ by dental plan. Fees for non-covered services along with deductibles and copayments are due at the time of service. CANCELLATION POLICY: A fee of $100 will applied if an appointment is cancelled or broken without a 24-hour notice. We reserve the right not to make future appointments if this occurs more than twice. This fee is subject to change without notice. PAYMENT POLICY: We accept cash, personal checks, and credit cards. LATE FEES: A service charge of 1.75% per month (21% per annum) on the unpaid balance will be charged on all accounts exceeding sixty (60) days, unless previously written financial arrangements are satisfied. I have read the above conditions of treatment and payment and agree to their content. HIPAA Compliance Patient Consent FormOur Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified on your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that: Protected health information may be disclosed or used for treatment, payment or healthcare operations The practice reserves the right to change the privacy policy as allowed by law The practice has the right to restrict the use of information, but the practice does not have to agree to those restrictions The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease The practice may condition receipt of treatment upon execution of this consent May we phone, email or send a text to you to confirm appointments?* Yes No May we leave a message on your answering machine at home or on your cell phone?* Yes No May we discuss your dental conditions with any member of your family?* Yes No Please name the family members allowed* Insurance Clarification and PolicyWe always try our very best to work with your dental insurance in order to obtain fair and correct reimbursement from them. However, please keep in mind that insurance coverage and reimbursement are never guaranteed and that we cannot force them to pay. You may not realize how much time and effort we must put in every day into our dealing with all insurance companies on your behalf. For example, just to simply verify your coverage, our staff member can be put on hold for up to 2 hours since most calling centers are not in the United States. Regarding treatment estimates, they are purely just “estimates!” Also, Insurance may confirm that they have received the claims, but we do not get paid until at least 30 to 60 days after we have submitted the claims. Therefore, please be patient and do not call us about a claim unless it has been 60 days since you had the treatment rendered. Finally, if your insurance refuses to pay for any services already rendered, you will have to pay us for the services rendered within 30 days. Thank you. Dr Tri M Le
