New Client Forms (中文)
Patient Information Form
Last Name:  First Name:  Middle Initial: 
Mailing Address: (Street, City, State, Zip) 
Birthday: 
Home Phone:  Work Phone:  Cell Phone: 
Email Address:  Do you want Email reminders?
Social Security Number:  Drivers License Number: 
Occupation:  Employer:  Employer Phone: 
Employer Address: (Street, City, State, Zip) 
ln Case of Emergency Contact
Name:  Relationship: 
Home Phone:  Work Phone:  Cell Phone: 
Whom can we thank for referring you to us? 
INSURANCE INFORMATION
PRIMARY DENTAL INSURANCE CO INSURANCE ID # 
NAME OF POLICYHOLDER SOCIAL SEC# --
POLICYHOLDER DATE OF BIRTH(MM/DD/YY) //
RELATIONSHIP OF PATIENT TO POLICYHOLDER(SELF/SPOUSE/CHILD) SEX(M/F) 
NAME OF EMPLOYMENT PHONE# 
ADDRESS CITY ST  ZIP 
Last Name:  First Name:  Middle Initial: 
Mailing Address: (Street, City, State, Zip) 
Birthday: 
Home Phone:  Work Phone:  Cell Phone: 
Email Address:  Do you want Email reminders?
Social Security Number:  Drivers License Number: 
Occupation:  Employer:  Employer Phone: 
Employer Address: (Street, City, State, Zip) 
Insurance Company:  ID Number:  Group Number: 
I do authorize and give consent to my Dentist and his/her Dental Team to administer treatment, including, but not limited to local anesthesia, analgesia, and other such treatment which may be necessary for the above named patient.
I understand that I am responsible for all costs of dental treatment. I authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I authorize the dentist to release all infomation necessary to secure payment of benefits.
Patient or Responsible Party Signature: X   Date:
ADAIDM/12-08

Medical History Form
Although our Dental Team primarily treats areas in and around your mouth the health of your entire body can influence treatment you may receive. Certain health conditions or medication can have significant interactions with the dentistry you may receive. Please answer the following questions as accurately as possible, Thank You!
Are you under a physician’s care now? If yes, please explain: 
Have you ever been hospitalized or had a major operation? If yes, please explain: 
Have you ever had a serious head or neck injury? If yes, please explain: 
Have you ever taken, Phen-Fen, Redux, Fosamax?
Are you on a special diet? If yes, please explain: 
Do you use tobacco?
Do you use controlled substances? If yes, please explain: 
Please list any medications, pills, or drugs you are taking: 
Women
Are you pregnant or trying to get pregnant? Taking oral contraceptives? Nursing?
Are you allergic to any of the following?
If yes, please explain: 
Do you have, or have you had, any of the following?
Please Explain: 

Signature
I certify that the above information is correct to the best of my knowledge. I understand that providing incorrect information can be dangerous to my (or my patient’s) health I will not hold my Dentist or any members of his/her Dental Team responsible for errors or omissions that I have made in completion of this form. It is my responsibility to notify my Dentist of any changes in the above medical status.
Patient or Responsible Party Signature: X   Date:
ADAIDM/12-08

CLIENT RIGHTS AND HIPAA AUTHORIZATIONS
The following specifies your rights about this authorization under the Health Insurance Portability and Accountability Act of 1996, as amended from time to time (“HIPAA”).
1.
Tell your provider if you do not understand this authorization, and the provider will explain it to you.
2.
You have the right to revoke or cancel this authorization at any time, except: (a) to the extent information has already been shared based on this authorization; or (b) this authorization was obtained as a condition of obtaining insurance coverage. To revoke or cancel this authorization, you must submit your request in writing to provider at the following address (insert address of provider):
3.
You may refuse to sign this authorization. Your refusal to sign will not affect your ability to obtain treatment, payment, enrollment or your eligibility for benefits. However, you may be required to complete this authorization form before receiving treatment if you have authorized your provider to disclose information about you to a third party. If you refuse to sign this authorization, and you have authorized your provider to disclose information about you to a third party, your provider has the right to decide not to treat you or accept you as a patient in their practice.
4.
Once the information about you leaves this office according to the terms of this authorization, this office has no control over how it will be used by the recipient. You need to be aware that at that point your information may no longer be protected by HIPAA. If the person or entity receiving this information is not a health care provider or health plan covered by federal privacy regulations, the information described above may be disclosed to other individuals or institutions and no longer protected by these regulations.
5.
You may inspect or copy the protected dental information to be used or disclosed under this authorization. You do not have the right of access to the following protected dental information: psychotherapy notes, information compiled for legal proceedings, laboratory results to which the Clinical Laboratory Improvement Act (“CLIA”) prohibits access, or information held by certain research laboratories. In addition, our provider may deny access if the provider reasonably believes access could cause harm to you or another individual. If access is denied, you may request to have a licensed health care professional for a second opinion at your expense.
6.
If this office initiated this authorization, you must receive a copy of the signed authorization.
7.
Special Instructions for completing this authorization for the use and disclosure of Psychotherapy Notes. HIPAA provides special protections to certain medical records known as “Psychotherapy Notes.” All Psychotherapy Notes recorded on any medium by a mental health professional (such as a psychologist or psychiatrist) must be kept by the author and filed separate from the rest of the client’s medical records to maintain a higher standard of protection. “Psychotherapy Notes” are defined under HIPAA as notes recorded by a health care provider who is a mental health professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint or family counseling session and that are separate from the rest of the individual’s medical records. Excluded from the “Psychotherapy Notes” definition are the following: (a) medication prescription and monitoring, (b) counseling session start and stop times, (c) the modalities and frequencies of treatment furnished, (d) the results of clinical tests, and (e) any summary of: diagnosis, functional status, the treatment plan, symptoms, prognosis, and progress to date. Except for limited circumstances set forth in HIPAA, in order for a medical provider to release “Psychotherapy Notes” to a third party, the client who is the subject of the Psychotherapy Notes must sign this authorization to specifically allow for the release of Psychotherapy Notes. Such authorization must be separate from an authorization to release other dental records.
8.
You have a right to an accounting of the disclosures of your protected dental information by provider or its business associates. The maximum disclosure accounting period is the six years immediately preceding the accounting request. The provider is not required to provide an accounting for disclosures: (a) for treatment, payment, or dental care operations; (b) to you or your personal representative; (c) for notification of or to persons involved in an individual’s dental care or payment for dental care, for disaster relief, or for facility directories; (d) pursuant to an authorization; (e) of a limited data set; (f) for national security or intelligence purposes; (g) to correctional institutions or law enforcement officials for certain purposes regarding inmates or individuals in lawful custody; or (h) incident to otherwise permitted or required uses or disclosures. Accounting for disclosures to dental oversight agencies and law enforcement officials must be temporarily suspended on their written representation that an accounting would likely impede their activities.
Authorization and Signature: I authorize the release of my confidential protected dental information, as described in my directions above. I understand that this authorization is voluntary, that the information to be disclosed is protected by law, and the use/disclosure is to be made to conform to my directions. The information that is used and/or disclosed pursuant to this authorization may be re-disclosed by the recipient unless the recipient is covered by state laws that limit the use and/or disclosure of my confidential protected dental information.
Signature of the Client: 
Signature of Personal Representative: 
Relationship to Client if Personal Representative: 
Date of signature: 
//

Email: 
* Verify Code:
Can't see clear?click me