PATIENT REGISTRATION First Name: Patient Is: Policy Holder Responsible Party Last Name: Middle Initial: Preferred Name: Responsible Party ( if someone other than the patient ) First Name: Last Name: Middle Initial: Address: Address 2: City, State, Zip: Pager: Home Phone: Work Phone: Ext: Cellular: Birth Date: Soc Sec: Drivers Lic: Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder Patient Information Address: Address 2: City: State / Zip: Pager: Home Phone: Work Phone: Ext: Cellular: Sex: Male Female Marital Status: Married Single Divorced Separated Widowed Birth Date: Age: Soc Sec: Drivers Lic: E-mail: I would like to receive correspondences via e-mail. Section 2 Section 3 Employment Status: Full Time Part Time Retired Student Status: Full Time Part Time Pref. Dentist: Employer ID: Pref. Pharmacy: Carrier ID: Pref. Hyg: Referred By Previous Dentist Emergency Contact Primary Insurance Information Name of Insured: Relationship to Insured: Self Spouse Child Other Insured Soc. Sec: Insured Birth Date: Employer: Address: Address 2: City, State, Zip: Rem. Benefits: Rem. Deduct: Ins. Company: Address: Address 2: City, State, Zip: Insured Birth Date: Employer: Other Insured Soc. Sec: Address: Rem. Benefits: Rem. Deduct: Address 2: City, State, Zip: Secondary Insurance Information Name of Insured: Spouse Child Relationship to Insured: Self Ins. Company: Address: Address 2: City, State, Zip: Emergency Contact #
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PATIENT REGISTRATION - Dentist Warner Robins · 200 Corporate Pointe, Warner Robins, GA 31088 Phone 478.922.5882 Fax 478.922.5910 I understand that it is my right to refuse to sign
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PATIENT REGISTRATION
First Name:
Patient Is:
Policy Holder
Responsible Party
Last Name: Middle Initial:
Preferred Name:
Responsible Party ( if someone other than the patient )
First Name: Last Name: Middle Initial:
Address: Address 2:
City, State, Zip: Pager:
Home Phone: Work Phone: Ext: Cellular:
Birth Date: Soc Sec: Drivers Lic:
Responsible Party is also a Policy Holder for Patient
Primary Insurance Policy Holder
Secondary Insurance Policy Holder
Patient Information
Address: Address 2:
City: State / Zip: Pager:
Home Phone: Work Phone: Ext: Cellular:
Sex:
Male
Female Marital Status:
Married
Single
Divorced
Separated
Widowed
Birth Date: Age: Soc Sec: Drivers Lic:
E-mail:
I would like to receive correspondences via e-mail.
Section 2
Section 3
Employment Status:
Full Time
Part Time
Retired
Student Status:
Full Time
Part Time
Pref. Dentist:
Employer ID: Pref. Pharmacy:
Carrier ID: Pref. Hyg:
Referred By
Previous Dentist
Emergency Contact
Primary Insurance Information
Name of Insured: Relationship to Insured:
Self
Spouse
Child
Other
Insured Soc. Sec: Insured Birth Date:
Employer:
Address:
Address 2:
City, State, Zip:
Rem. Benefits: Rem. Deduct:
Ins. Company:
Address:
Address 2:
City, State, Zip:
Insured Birth Date:
Employer:
Other
Insured Soc. Sec:
Address:
Rem. Benefits: Rem. Deduct:
Address 2:
City, State, Zip:
Secondary Insurance Information
Name of Insured:
Spouse
Child Relationship to Insured:
Self
Ins. Company:
Address:
Address 2:
City, State, Zip:
Emergency Contact #
MEDICAL HISTORY
PATIENT NAME _______________________________________________ Birth Date _____________________________________
Do you have, or have you had, any of the following?
Yes No
Are you allergic to any of the following?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can bedangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE OF PATIENT, PARENT, or GUARDIAN __________________________________________________ DATE ______________________
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may
following questions.have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the
If yes, please explain:Are you under a physician's care now? Yes No
Have you ever had a serious head or neck injury?Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Yes No If yes, please explain:Yes No If yes, please explain:Yes No If yes, please explain:
Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No
Swelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice
Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No
Other
Aspirin
If yes, please explain:
Pregnant/Trying to get pregnant? Yes No Taking oral contraceptives? Yes No Nursing? Yes NoWomen: Are you
Are you on a special diet? Yes NoDo you use tobacco? Yes No
Do you use controlled substances? Yes No
Yes No
Have you ever been hospitalized or had a major operation?
Have you ever taken Fosamax, Boniva, Actonel or anyother medications containing bisphosphonates? Yes No
Yes No
Metal Latex Sulfa drugsPenicillin Codeine Local Anesthetics Acrylic
High Cholesterol
Osteoporosis Yes No
DAVIS DENTAL CARE RYAN DAVIS,DMD
DAVIS DENTAL CARE
Ryan R. Davis, DMD 200 Corporate Pointe
Warner Robins, GA 31088 Phone 478.922.5882
Acknowledgement of Receipt of
HIPAA Notice of Privacy Practices
Last Updated: April 2015
ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES
Acknowledgement
I, ______________________________________, hereby acknowledge that I have received and reviewed a copy of DAVIS DENTAL CARE’s HIPAA Notice of Privacy Practices.
I understand that DAVIS DENTAL CARE’s HIPAA Notice of Privacy Practices may change periodically and that I am entitled to receive a copy of DAVIS DENTAL CARE’s revised HIPAA Notice of Privacy Practices upon request.
I understand that, if I have questions about DAVIS DENTAL CARE’s HIPAA Notice of Privacy Practices, I may contact
DAVIS DENTAL CARE Ryan R. Davis, DMD 200 Corporate Pointe, Warner Robins, GA 31088 Phone 478.922.5882 Fax 478.922.5910
I understand that it is my right to refuse to sign this Acknowledgement should I so choose, and that DAVIS DENTAL CARE will not refuse treatment to me if I refuse to sign this Acknowledgement.
I further understand that I may contact the Secretary of the U.S. Department of Health and Human Services should I have concerns regarding DAVIS DENTAL CARE’s privacy policies and procedures. For information on how to contact the U.S. Department of Health and Human Services, please ask Dr. Ryan Davis, noted above, for assistance.
Patient Signature Date
Signature of Personal Representative Print Name of Personal Representative
Relationship of Personal Representative to Patient
FOR OFFICE USE ONLY DAVIS DENTAL CARE made a good-faith effort to obtain Acknowledgement, from the patient noted above, of receipt of its HIPAA Notice of Privacy Practices. In spite of these efforts, DAVIS DENTAL CARE was unable to obtain a signed Acknowledgement for the following reason(s):
Refusal to sign Acknowledgement on _____________________________, 20______.
Communications barriers prohibited us from obtaining a signed Acknowledgement.
An emergency situation prohibited us from obtaining a signed Acknowledgement.
Other (Describe):_______________________________________________________