Patient Registration Form Amoricah O.ntal Asociatknw*vr.!d!.org

Emao: Today's Data:

Prri.rrld Nanr: O Mi!3 O Mr. O M.!. O Mr. 3 Dr.

Nem6: Ho.rl! Phon : rEiro r- @d Cai Ptlql: rri ra r €d.()()City: Slet6: zip:

ss4: Oate of 8i6h: Sex: M F

€mplovor: 8ui6o!a Phona: r'.r.d .! codr()EnErgoncy Conl.ct Rdatboshrp: Home Pltona: ftr,6.'r6a C6ll Phona: ,-^n ,e 6d() ()

Bsrsr orovac aahcol in,o: Sclrool N6d€:

O ffdowed Addr.ss 2:

Pholle; i City, Slate, A9:_

Student Status: J Fr,[ nn|a 3 Pari Tme

3 Flll 'l'im. ;l PaIt llme I Ronr6d

Marital Status: 3 Marded

Dental lnsurance lnformation

9s€f tr soousr OchiE C other

Sacondary lnsureoc. lirdraadon

Rdattd6trip to Patirnr:

lftlu16d 8nh Dde:

asett 3 spouse achitd El os'€r

lnsirrEd Soc. Sec-:

Employer: lnr. Cornpafiy:

Adaksls:

Addr-! 2:

Cdy. Strte, Zp:

Acldrgss:

Ad6r.33 2:

,or:

Dental lnformation For lhe !o th.Yaa

Oo your gt[ns bta6d wh6n Fo bru.lt or io6s?. , , . . - . . . - EArr yc.!'tarth saotiltya to cokt. hol. s(aatr oa pa!s3,r.?. Uls yol, nlouth day? ............ CHaw you hod any Fsiodqrtal 6ur0lr..*nctt ...,... AHrv. F, .Yf, tid oahoddttic (baac-) tr.t ncnli?. . . . . OHav€ ),o{r hrd srry Fobbal}3 *ssocrsted wrh rrftl'/,ot',sdenlal trrrlrncotl ...-........, O

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Yei No OKOo yqJ har,a arlatrr! or nex franr? O C ODo yo! navc ryry dicl&!. poppliq or dhcofifort h thc Jcr.? 0 O gOoyoq b.rq o.g'hd your t-irr? ............... .,... U tr DOoyorrhavr so.E qdcs!hyo{, ma{nh?............ ! C CDo yo!,rrE dcnt 6 or p.nials? . . ... . , . . . . . . . . . . . . f :J UDo yo! pdioipdr h.cliv6 rEiqadond Etivitic., . . . -.. A J OHrv6 yolr !*r h.d . a.iolJ6 lr*-ry to yq, hald o( ftouth? ,l I 3

ls lol, ho.n w6t!r 3uppry nt ort6.fd? O 3 ODo you drink bottlcd o. fflt@d waii? . . .. . . .. . , . . .. . , O f 3It ye., htr ottcn? Circlc d!!, DA&Y / WEEXLY / OCCASTOMLT-YAre ./(ru cunirnt arF.iaod.lg d6tta, pain or dscorrfu? tr f, -l

DeL ol your last ddlial 6ren:t\lhai wrs doo. at that ttnE?

Oeta of lsst d.rrtd r-rlys:

What rs th€ r.ason for your d. d yisn bdsy?

How do you t6€l about yoor s.inle?

Primary lnlureoc. lntonnalion

lasrrEd Soc. Sec.r

Chy, State. Zip:

lnsurcd E.th Oate

1lr3 Co.nprny:

Addr!6l 2:

City, St t., Zp:

rD*:

Time 3:07PI\!

PabentNffi:

Are you wtder a ph,/soan's care nEnl

Have you ever been hosptdized or had a major operatbn?

H6ve you ever had a serirus head or neck inyry?

Are ytu takrE any medications, p{ls, or drugs?

Do yor: take, or have you Eken, PhenfEr or Redux?

Have you ever takEn Foffix. Boriva, Actonel or any odrermediEtions contahng t sphosphoflates?

Are yoj on a speod clietT

Do you ure tobacol

Do you use contoned sr.6stances?

ltlomm; Are you,..

'PregnanqTrvng to get pregnat)

Eskdla Dental Ioc,

Eagl€soft }ledrcal HktoryBirth Ddte:

If yes

If ,/es

If yes

BatE 1Ii15i2018

Date (reated:

taking, cruld have il rnporiilt interrelatimshrp r+ith the denbstry yo.t willrteive. Thar* you fo ansrvatng the fo{o*'ing quetions.

,i.-'i Yes i.

t.-.: Yes 1.

r- :Yes 1'-.)No

.;Yes i .,No lfYes

No

No

i. iYes i :No

.. : Yes i "'l No

r :Yes r -rNo

i iYes i'itlo

If yes

If yes

i.:"]Yes ,JNo ifyes

t''-lM*"rsr ! ltakrng oral conbaceptses)

ArE you alerEc to any of the fu,llowng?

-.,llsprrin, lMetal

Oiher?

I lPenEfim

[-]t-atex

i-lcodmei lsutfa orugs

Ll Esyfic

l--jLocal lnethetia

RodiatoflTreatnenE , :yEs iRecent UeEht Loss tes

Renal Didyss yes

Rhzumatr Fevs yes

Rhemabsn yes

scarl€t Fever yes

Shingrles , Yes i

Siclde Cell Dseas€ ' /es

9nus Tro-Ue yes

Spnra Elifida , yes ..

StsGdlflntesbnalDseaft yes

Sboke yEs

S*elfing of Lunbs yes

Th\rad Dsease fes

Tmellitii ytr

Tuberculosrs yas

Tunors or Growdts yes

Ulcss Yes

Venereai Dsease '/es

Yello* laundlce ,. : yes i.

i:l If yes

Do you have, or have ym had" any of the fo{loxng?

AIDSltiMositive

Alzheirner's Disease

Anaphtltaxis

Anemia

Angna

Ar&ri6s,lGout

Artifi,:d Jornt

Asthma

Blood Dsease

Elood Transfusion

Breathrng Problems

Bruise EaSy

(anEer

ChemoSrerapy

Chest Pans

..,:Yes i lHo

r"-,ifq5 1-.,tlo

r--)Yes i lNo

r"r Yes i. ) No

,.,:Yes l. -:f{o

'..'Yes l..lruo

ArtifioalHeart'falve'lyes l.':No

'-:ves i 't'lo.-.1Yes i' I No

.iVes l-",wo' 'I'Ys | ': tio'':Ytr i -rl'lo

.',: Ves r -: tlo

.'.i Ves l.-.: No

.-,r Yes ! _.) No

.-tYes t-,itloCoid Soresfever Blsters i .;

ys t. .: No

Cong€nital Heart Dsorder Yes No

Con rulsrons yes llo

CortsonEl'ledicir€ i..:yes i,:NsDiabetes i_,yes

':.;N0DrugAddtction i lyes i"ll{oEasiy lr/inded yes ,l'.lo

Emphysema . Y6 :lloEBlepsy or Seizures ' yes .. No

Excess';e Beedmg - yes . tvo

Excess{ve Tkst Yo -. t to

Fainbng SpelkTDzmss Yes No

Freqrentcouqh i.:yes i:Nofte+rent Darhea yes lto

Fre+rent l-teadadres yes tto

Genitai l*erpes ys hb

Glawsm /es - tOHay Fever _ ys I'b

Hent Atia*Fadure i .: Yes , '":

tio

HeartMurmr yes _,i,lo

Hetri Paemaktr ,Yes . 't'lo

Hefft Troi.rbl€Fisease i : yes t.-: [b

Hemophilia

Flepatts A

Hryatttis E or C

Herpeg

Fhgh Elood Pressure

High €holesteroi

Hi,res or Raslr

Hypogrlycemra

Iregular He*f:eatl(dnev Probkms

Lflkemra

Liver DiRa*Lolr Blood Presqre

Lmg Disease

Mtd ualve Prolapse

Osteopoross

Pain ifl law -lsintg

Parathyroid D*aePsychEtsrc Care

:..}es .uo

,' '(es , llo

r;Yes I.Flo

1 Ies . llor. ,,ies i .llo

'' Yes flo':Yes

fio

les ' tlo' Yes ilo

res I lo

Yes f.lo

fEs llo

.. YEs,.. l.lo

.. Fes : ll0

. r'es tlo.. .l Yes : ll0

, fes t'10

. '{es llo

1' fes I flo

iNo

:NO

'llo

., irlo

No

'lto, I'lo

, l'.lo

., l,to

iNo

,{o:No

:NO

;NA

, !\,lo

j ilo

:No

: t{o

!{orNo

Have ym ever had any serious dness not listed aho're7

Cmts:

i. iYes i.,.rNo Ifyes

i

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:

re$onshility to inftrm *e dental office of my drag€s in mediffilstahrs.

Sigflatre ofPatrent, Parent or Qrardafl:

X Date:

$strelloHI PPA/PATI ENT I N FORMATION

I understand that I have certain rights to privacy regarding my protected health.These rights are given to me under the Health lnsurance Portability and AccountabilityAct of 1996 (HIPPA). I understand that by signing this consent, I authorize you todisclose my protected health information to carry out.

. Treatment (including direct or indirect treatment by other healthcareproviders involved in my treatment)

. Obtaining payment by third party payers (e.g. insurance companies)

. The day-today healthcare operations of your healthcare practice

I have also been informed of and given the right to review and secure a copy of theNotice of Privacy Practices, which contains a more detailed description of the uses anddisclosures of my protected health information and my rights under HIPPA. I am awarethat you have the right to change the terms of this notice and that I may contact you atany point in time to obtain the most recent copy of this notice.

I understand that I have the right to request restrictions on how my protected healthinformation is used disclosed to carry out treatment, payment, and healthcareoperations, but 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 ordisclosure that occurred prior to the date I revoke this consent is not affected.

I acknowledge that I have read and understand this consent and the meaning of itscontents. Any and all questions have been answered in a satisfactory manner and I

believe that I have sufficient information to give this informed consent. I furtherunderstand that this consent shall remain in effect until terminated by myself.

Print Patient Name:

Person Authorized for Consent: Relationship to Patient:

Signature: Date:

Office Staff Member:

$slrelloINITIAL CONSENT AND AUTHORIZATION AGREEMENT

tPlease read this form carefully. Should you have any questions, our team will be happy to assist you.-

1.) t, hereby authorize the dentists at Estrella Dental to perform dental treatment with the use ofany necessary or advisable radiographs (X-Rays) and/or any other diagnostic aids in order to complete a thorough

diagnosis and treatment plan.2.) I also authorize the dentists to use photographs, radiographs, other diagnostic materials, and treatment recordsfor the purposes of advertising, teaching, research, and scientific publication and, in any such publication or use no

patient will be identified by name.3.) Certain parts of dental treatment may be performed by dental assistants and dental hygienists.

4.) Estrella Dental is not responsible for previous dental treatment that may need replacing.5.) I realize that guarantee of results or absolute satisfaction are not always possible in dental health service. I

understand that my compliance as a patient and full dental and medical history affect success.

To the best of my knowledge, the questions on the patient's registration form have been accurately answered. I

understand that providing incorrect information can be dangerous to my health. lt is my responsibility to inform thedental office of any change in my medical status. I authorize the dentist to release any pertinent information includingthe diagnosis and the records of any treatment or examination rendered to me during the period of such dental care

to third party payers, and/or other health practitioners.

lnitial:

FINANCIAL AGREEMENTEstrella Dental realizes that every person's financial situation is different, so we have worked hard to provide

a variety of payment options to help you receive the dental care needed to enjoy a healthy and confident smile withrespect to your budget. Payment is due prior to the rendering of services.

DENTAL INSURANCEDental lnsurance may cover only part of your dental treatment; we can only provide you with an ESTIMATE based onyour benefit plan. I understand and agree to be responsible for the entire balance on my account after 90 days,

regardless of any insurance coverage. Please understand that the contract for dental insurance is between youand your insurance company. As a courtesy, there is no charge for submitting your insurance claim.

PAYMENT PLANWe offer and accept third party financing for patients who prefer to make extended monthly payments. An easy credit

application is completed and credit is approved or denied. lf you are interested in financing your dental treatment,please let our staff know so we can assist you with an application. We may have a response today making your ability

to receive treatment almost immediate.

&CareCredif"

LendingClub

Patient Signature: Date: