Patient Paperwork

Fields marked with an * are required

First Name *

Middle Name

Last Name *

Date Of Birth *

Sex *

How'd You Hear About Us? *

Social Security Number

Marital Status *

Phone Number (Home)

Phone Number (Work)

Phone Number (Cell Phone) *

Address

City

US States

Zip

Occupation

Spouse's Name

Primary Dental Insurance Name

Member ID Number

Member Group Number

Insurance Subscriber First Name

Insurance Subscriber Last Name

Insurance Subscriber Date of Birth

Relation To Patient

Is patient covered by additional insurance?

Insurance Subscriber First Name Copy

Insurance Subscriber Last Name Copy

Dental Insurance Name

Member ID Number

Member Group Number

Insurance Subscriber Date of Birth

Relation To Patient

ASSIGNMENT AND RELEASE *

I certify that I, and/or my dependent(s), have insurance coverage with __(Listed Above)__and assign directly to Dr.__(Ali Fatemi)__all insurances benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named dentists may use my health care information and may disclose such information to the above-named insurance company (ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related service.

First Name *

Signature of Patient, Parent, Guardian, or Personal Representative

Last Name *

Signature of Patient, Parent, Guardian, or Personal Representative

Relationship to Patient *

Today's Date *

Reason for today’s visit *

Former Dentist

City/State

Date of last dental visit

Date of last dental X-rays

Please a mark on “yes” or “no” to indicate if you have had any of the following:

Bad teeth *

Blisters on lip/mouth *

Bleeding gums *

Chew on one side of mouth *

Burning sensation on tongue *

Cigarette, pipe, or cigar smoking *

Clicking or popping jaw *

Dry mouth *

Fingernail biting *

Food collection between the teeth *

Grinding tooth *

Gums swollen or tender *

Jaw pain or tenderness *

Lip or cheek biting *

Loose teeth or broken fillings *

Mouth breathing *

Mouth pain, brushing *

Orthodontic treatment *

Pain around ear *

Periodontal treatment *

Sensitivity to cold *

Sensitivity to heat *

Sensitivity to sweets *

Sensitivity to biting *

Sores or growths in your mouth *

How often do you floss? *

How often do you brush? *

Height *

Weight *

Age *

Are you in good general health *

Has there been ANY change in your general health in the past year *

My last Physical Examination was on, approximate date?

Are you PRESENTLY under a physician’s care? *

If YES, what condition?

The physician’s name and address:

Have you had any serious illness or operation? *

If YES, please list:

Have you been hospitalized or had a serious illness within the past 5 years? *

Do you or have you ever had any of the following, Please Check: *

Heart trouble
Heart attack
Coronary insufficiency
Stroke
Damaged heart valves
Congenital heart disease
NO

Rheumatic heart disease, heart murmur? *

Chest pain after exertion? *

Shortness of breath after mild exercise? *

Do your ankles swell? *

Do you use extra pillows to sleep? *

Do you have a cardiac pacemaker? *

Do you have any blood pressure problems? *

Epilepsy? *

Fainting spell? *

Seizures? *

Emotional disturbances? *

Do you follow any treatment for a nervous disorder? *

Do you have a persistent cough or cold? *

Do you have or have ever had tuberculosis? *

Is there ANY history of tuberculosis in your family? *

Do you have any sinusitis, sinus trouble? *

Do you have emphysema, chronic bronchitis, asthma? *

Do you have ANY stomach ulcers? *

Do you have or have you ever had:

Hepatitis? *

Jaundice? *

HIV/AIDS *

Liver disease? *

Have you ever vomited blood? *

Do you have ANY diarrhea? *

Do you have diabetes? *

Does anyone in your family have diabetes? *

Do you urinate more than six times a day? *

Are you thirsty very often or do you have a dry mouth? *

Do you have hypothyroidism or hyperthyroidism? *

Do you have anemia, Sickle Cell disease, blood disorder? *

Is there ANY family history of blood disorders? *

Are you hemophilic? *

Have you had abnormal bleeding after any surgery, extraction, or trauma? *

Have you ever had a blood transfusion? *

Immunodeficiency problem? *

Are you allergic to or have you acted adversely to:

Local anesthetics? *

Antibiotics, Penicillin, Sulfa Drugs? *

Barbiturates, sedatives, or sleeping pills? *

Aspirin? *

Iodine? *

Codeine or other narcotics? *

Others, please specify: *

Others, please specify:

Do you have asthma or hay fever? *

Do you have or have you ever had hives or skin rash? *

Kidney trouble? *

Syphilis, gonorrhea? *

Herpes? *

Arthritis? *

Inflammatory rheumatism? *

Bone infection? *

Osteoporosis? *

Tumor or malignancy? *

Chemotherapy, or radiation therapy? *

Do you have or have you ever had ANY disease, condition, or problem NOT listed above that you think we should know about? *

If so please explain:

Are you regularly exposed to x-ray or ANY other ionizing radiation or toxic substances? *

Do you have glaucoma? *

If so:

Wide
Close

Are you wearing or do you wear contact lenses? *

Do you drink alcohol? *

If so how often?

Do you smoke or use oral tobacco? *

If so how often?

Are you taking any of the following medications:

Antibiotics or sulfa drugs? *

Anticoagulants, blood thinning agents? *

Medicine for high blood pressure? *

Tranquilizers? *

Iodine? *

Codeine or other narcotics? *

Bisphosphonate? *

Other? *

If so please explain:

FOR WOMEN:

Are you pregnant?

Are you nursing?

Do you have any problems associated with your menstrual period?

Are you taking oral contraceptives or hormonal therapy?

What is your chief dental complaint?

Please explain:

Are you experiencing any discomfort or pain at this time? *

Are you satisfied with the appearance of your teeth? *

Are you able to eat and chew foods satisfactory? *

Do you have headaches, ear aches, or neck pain? *

Do you frequently experience sinus problems? *

Have you had ANY serious trouble associated with ANY previous dental treatment? *

If yes, please explain:

General Dental Responsibility *

I hereby authorize and request the performance of dental service for myself or for: I also give my consent to ANY advisable and necessary dental procedures, medications or anesthetics to be administered by the attending dentist or his supervised staff for diagnostic purposes or dental treatment. These records may include study models, photographs, x-rays, and blood studies. I understand and acknowledge that I am financially responsible for the services provided for myself or the above name, regardless of insurance coverage. Treatment plans involving extended credit circumstances are subject to a credit check. I also understand that the treatment estimate presented to me is only an estimate. Occasionally, the need may arise to modify treatment. In such a case, I will be informed of the need for additional treatment, and its fee modification. To the best of my knowledge the information provided in this form is accurate.

Notice of Privacy Policy *

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully. Understanding your Health Record A record is made each time you visit a hospital, physician, or other health care provider. Your symptoms, examinations and test results, diagnoses, treatment, and a plan for future care are recorded. This information is most often referred to as your “health” or “medical” record, and serves as a basis for planning your care and treatment. It also serves as a means of communication among any and all other health professionals who may contribute to your care. Understanding what information is retained is your record and how that information may be used will help you ensure its accuracy, and enable you to relate to who, what, when, where, and why others may be allowed access your health information. This effort is being made to assist you in making informed decisions before authorizing the disclosure of your medical information to others. You’re Health Information Rights: • You have the right to inspect and copy your protected health information. • You have the right to request a restriction of your protected health information. • You have the right to request to receive confidential communications from us by alternative means or at an alternative location. • You may have the right to have your provider amend your protected health information. • You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information. • You have the right to obtain a paper copy of this notice from us. Our Responsibilities This office is required to maintain the privacy of your health information and to provide you with notice of our legal commitment and privacy practices with respect to the information we collect and maintain about you. This office is required to abide by the terms of this notice and to notify you if we are unable to grant your requested restrictions or reasonable desires to communicate your health information by alternative means or to alternative locations. This office reserves the right to change its practices and effect new provisions that enhance the privacy standards of all patient medical information. In the event that changes are made, this office will notify you at the current address provided on your medical file. Other than reasons described in this notice, this office agrees not to use or disclose your health information without your authorization. To Receive Additional Information or to Report a Problem For further explanation of this notice, you may contact our staff at (301) 737-4747 If you believe your privacy rights have been violated, you have the right to file a complaint with our office or with the Secretary of Health and Human Services with no fear of retaliation by this office. Uses and Disclosures of Protected Health Information Treatment- Information obtained by your health practitioner in this office will be recorded in your medical record and used to determine the course of treatment that should work best for you. This consists of your physician recording his/her own expectations and those of others involved in providing you care, such as specialty physicians or lab technicians. Payment- Your health care information will be used in order to receive payments for services by this office. A bill may be sent to either you or a third part payer with accompanying documentation that identifies you, your diagnosis, procedures performed and supplies used. Health Care Operations- The medical staff in this office will use this authorization at any time, in writing, except to the extent that we have taken an action in reliance on the use or disclosure indicated in the authorization. Other Permitted and Required Uses and Disclosures That May Be Made With Your Authorization or Opportunity to Object We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then we may, using professional judgement, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed. We will not use your health information for marketing communications without your written authorization. Other Permitted and Required Uses and Disclosures That May Be Made Without your Authorization We may use or disclose your protected health information in the following situations without your authorization: • Required by Law • Public Health • Communicable Disease • Health Oversight • Abuse or Neglect • Food and Drug Administration • Legal Proceedings • Law Enforcement • Coroners, Funeral Directors, and Organ Donation • Research • Criminal Activity • Military Activity and National Security • Workers Compensation • Inmates • Health and Human Services

Office Policy and Consent Form *

I hereby authorize “Fatemi Family Dentistry, LLC.” to apply for benefits on my behalf for covered services rendered. I certify that the information I have reported with regard to my insurance coverage is correct. I further authorize the release of any necessary information, including medical and dental information for this or any related claim to my insurance carrier. This authorization may be revoked by me or my insurance carrier at any time in writing. A copy of this authorization may be used in place of the original. Major dental work policy (crown, veneers, bridge, partial dentures, full dentures) We stand behind our treatment only when the patient is seen on a regular basis and is under our regular care every six months, or as recommended by the doctor. Any work that will require one hour appointments and/or may cost more than $300.00 will require a deposit of $100.00 per blocked hour before that appointment can be arranged. When you arrive to your appointment, that deposit will go towards your treatment. We require a 48 business hour advance notice of cancellation. You may not cancel your appointment during the weekend since we cannot fill that appointment time. I understand and agree that I am financially responsible for charges not paid by my insurance company. Charges not paid within 90 days by insurance company will be made “patient responsible.” I further agree in the event of non-payment, to be responsible for the cost of collections, and or court costs and any reasonable legal fees should this receive. I understand that returned checks will result in a $25.00 penalty.

Patient Signature: *

Today's Date *

Authorization for photographs *

I hereby authorize Fatemi Family Dentistry, LLC., their doctors, and their employees to take photographs of my dental conditions. These photographs may be used to aid in communication with a dental lab, other dental care providers, insurance companies, or for internal marketing purposes. I understand that I can revoke this authorization in writing at any time.

Patient Signature: *

Today's Date *

Acknowledgement and Receipt of Notice of Privacy Practices
(You may refuse to sign this acknowledgment)

I read Fatemi family dentistry’s notice of privacy and don’t require a copy.
have received a copy of Fatemi family dentistry’s notice of privacy practices.

Patient Signature: *

Today's Date *

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