Patient Registration Form Patient InformationToday's Date: MM slash DD slash YYYY Patient Name: First Middle Last Preferred Name: GenderMaleFemaleOtherMarital StatusMarriedSingleChildOtherSocial Security#: TDL#: Phone (Home):Work:Cell:Date of Birth MM slash DD slash YYYY E-mail Address Home Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Work Address: Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Employer Name: Position: How long there? Please list other members of your immediate family who are patients in our office:What is the reason for your visit today? Date of Last Dental Visit: MM slash DD slash YYYY Do you prefer Nitrous Oxide (laughing gas) during dental procedures? Yes No Are you interested in sedation dentistry? Yes No Are you interested in whitening your teeth? Yes No If you could change your smile, what would you do? Referral Information How did you find us?--select one--Family MemberCoworkerFriendDoctorLumineer or Invisalign ReferralInsurance CompanyGoogleOur WebsiteLetter in the MailYellow PagesLocationOtherCan we thank someone for referring you? Please provide their name. Medical HistoryAre you under a physician's care now? Yes No Why? Who? Phone: Have you ever been hospitalized or had a major operation? Yes No Discuss:Have you ever had a serious injury to your head or neck? Yes No Discuss:Are you taking any medications, aspirin, vitamins, herbals, pills or drugs? Yes No What?Are you on a special diet? Yes No Discuss:Are you allergic to any of the following medications or substances? Aspirin Penicillin Codeine Acrylic Metal Latex Rubber Milk None of the above Other Please specify:Women Please Check: Pregnant/trying to get pregnant Nursing Taking oral contraceptives Yes No Discuss:Do you now have or have ever had any of the following? Do you take any of these medicines? Please check appropriate boxes. *If yes to any of the starred conditions, please call prior to your appointment... premedication or changes in medication may be required. Heart Disease/Surgery * Yes No Excessive Bleeding Yes No Chemotherapy Yes No Night Sweats Yes No Cold Sores Yes No Heart Murmur or Defect * Yes No Sickle Cell Disease Yes No Osteoporosis Yes No Yellow Jaundice Yes No Fever Blisters Yes No Irregular Heart Beat Yes No Hemophilia Yes No Bisphosphonates* Yes No Kidney Problems Yes No Herpes Yes No Angina/Chest Pain Yes No Methemoglobinemia Yes No 0steonecrosis of Jaw Yes No Renal Dialysis Yes No Stroke Yes No Heart Attack/Failure Yes No Leukemia Yes No Aredia I.V. Reclast 1.V. Yes No Thyroid Disease Yes No Convulsions Yes No Congenital Heart Disorder * Yes No Recent Blood Transfusion Yes No Zometa I.V. Yes No Parathyroid Disease Yes No Epilepsy or Seizures Yes No Mitral Valve Prolapse * Yes No Swelling of Limbs Yes No Fosamaz, Actonel, Boniva * Yes No Arthritis/Gout Yes No Fainting or Dizziness Yes No Scarlet Fever Yes No Lung Disease Yes No Stomach/Intestinal Disease Yes No Rheumatism Yes No Glaucoma Yes No Rheumatic Fever * Yes No Breathing Problem Yes No Ulcers Yes No Pain in Jaw Joints Yes No Tumors or Growths Yes No Artifical Heart Valve * Yes No Shortness of Breath Yes No Recent Weight Loss Yes No Cortisone Medicine Yes No Nervousness Yes No Heart Pace Maker * Yes No Frequent Cough Yes No Frequent Diarrhea Yes No Artificial Joint * Yes No Psychiatric Care Yes No Pulmonary Shunt * Yes No Hay Fever Yes No Diabetes Yes No Sexually Transmitted Disease Yes No Alzheimer's Disease Yes No High Blood Pressure Yes No Sinus Trouble Yes No Excessive Thirst Yes No AIDS Yes No Allergies (Medicines) Yes No Low Blood Pressure Yes No Asthma Yes No Hypoglycemia Yes No HIV Positive Yes No Allergies (Pollen/Dust) Yes No Bacterial Endocarditis * Yes No Bloody Sputum Yes No Liver Disease Yes No Genital Herpes Yes No Hives or Rash Yes No Unexplained Fever Yes No Emphysema Yes No Hepatitis A (Infectious) Yes No Drug Addiction/ Alcoholism Yes No Need Premedication? Yes No Bruise Easily/Blood Disease Yes No Tuberculosis Yes No Hepatitis B or C Yes No Tattoos/Body Piercing Yes No Ever taken fen-phen? * Yes No Anemia Yes No Cancer Yes No Protease Inhibitor Yes No Cochlear implants? Yes No Coronary Stent * Yes No X-Ray Treatments (Radiation) Yes No Have you ever had any other serious illness not checked above? Yes No Discuss:Do you wish to talk to the dentist privately about any problem? Yes No To the best of my knowledge. all the preceding answers are correct. If I have any changes in my health status or if my medicines change, I shall inform the dentist and stall at the next appointment without fail. (Signature)Date MM slash DD slash YYYY HiddenReviewed By Doctor HiddenDate MM slash DD slash YYYY HiddenBP: HiddenPulse: HiddenHistory Review and Significant Findings Dental History Do your jaw joints make popping, clicking, or gritty sounds? Yes No Do you have frequent headaches or migraine headaches? Yes No How often do you awaken with head or jaw pain of unknown origin? Do you have concerns about snoring? Yes No Do you brush and floss on a routine basis? Yes No Discuss:Do you think you have active decay or gum disease? Yes No Do your gums ever bleed? Yes No Discuss:Do you ever have a bad taste in your mouth? Are you concerned about bad breath/Halitosis? Does food catch between your teeth? Any loose teeth? Do you want to keep your remaining teeth? Do you currently use tobacco? Yes No How long?Have you ever had any complications or allergic reactions following dental treatment? Yes No Please explain:We routinely use latex products for your safety. If you have a known sensitivity to latex products, please notify us prior to being called back to the treatment room. Insurance Information Name of Insured: First Middle Last ls insured a patient? Yes No lnsured's Birth Date: MM slash DD slash YYYY Social Security# Group# lnsured's Employer Name Patient's relationship to insured:SelfSpouseChildOtherDental insurance company name: Dental Insurance company phone number:*Please read and sign to have our office file you insurance: I authorize the release of information and understand that I am responsible for all cost of dental treatments. I hereby authorize payment directly to the below-name dentist of the group insurance benefits otherwise payable to me. Signature of patient, parent or guardianDate MM slash DD slash YYYY Upload Primary Insurance Drop files here or Select files Max. file size: 50 MB. Front and Back Image NeededUpload Secondary Insurance Drop files here or Select files Max. file size: 50 MB. Front and Back Image NeededUpload Driver's License/ID Card Drop files here or Select files Max. file size: 50 MB. Front and Back Image NeededFinancial Agreement As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. Insurance companies have a wide variety of rules and exclusions that the office may not be aware of. The office staff will estimate insurance coverage to the best of their ability but the patient agrees that this is an estimate only, not a guarantee of coverage. A service charge of 1 ½% per month (18% per annum) on the unpaid balance may be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I agree to have any photos taken of me to be used for education and training. I have read the above conditions of treatment and payment and agree to their content. Signature of patient, parent or guardianDate MM slash DD slash YYYY Relationship to Patient--select one--SelfSpouceChildOtherHIPAA Patient Consent Form I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIP AA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out: Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); Obtaining payment from third party payers (e.g. my insurance company); The day to day healthcare operations of your practice. I have also been informed of, and given the right to view and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIP AA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected. SignatureDate MM slash DD slash YYYY Relationship to Patient--select one--SelfSpouceChildOtherConsent for ServicesI voluntarily request Dr. Basil M. Moukarim as the dentist, and such associates, assistants and other health care providers as he may deem necessary to treat condition (s) as they relate to my hygiene care, to which I agree. I understand that each procedure will be fully explained to me and that additional treatment to be agreed upon in the future will be outlined on the treatment plan portion of my dental record. I understand that my dentist may discover other or different conditions that may require additional or different procedures than those planned. I authorize my dentist and such associates, assistants, and other health care providers to perform such procedures that are advisable in their professional judgement. I understand that there may be other problems associated with my oral condition that may be addressed at a later date. I understand that no warranty or guarantee has been made to me as to the result, cure, or longevity of dental work. I also give my consent for the taking of pictures, cast models, or any other dental documentation and allow the use of such pictures, casts, and models or other dental documentation by Dr. Basil Moukarim or Dental Illusions associates, in their lectures, teaching activities, or articles for publication. I fully understand that if I utilize insurance, I am responsible for any and all fees the insurance does not cover, including any and all fees to collect should the account be turned over for collection. I authorize Dr. Basil Moukarim to release any dental information or models that my insurance company deems necessary for the determination of this claim. I certify this form has been fully explained to me, that I have read it or have had it read to me, and that I understand its contents.SignatureDate MM slash DD slash YYYY Appointment Cancellation Policy We understand that unplanned issues can come up and you may need to cancel an appointment. If that happens, we respectfully ask for scheduled appointments to be cancelled at least 24 hours in advance. This will enable us to open otherwise unused appointments to better serve the needs of all patients. There will be a fee of $75 assessed if we do not receive a call to cancel an appointment within the 24 hour period. Thank you for being a valued patient and for your understanding and cooperation as we institute this policy. SignatureDate MM slash DD slash YYYY PhoneThis field is for validation purposes and should be left unchanged.