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    PATIENT REGISTRATION






    Policy Holder
    Responsible Party

    Responsible Party (if someone other than the patient)














    Responsible Party is also a Policy Holder for PatientPrimary insurance Policy Holder
    Secondary insurance Policy Holder

    Patient Information






    MaleFemale


    SingleMarriedDivorcedSeparatedWidowed








    I would like to receive correspondences via e-mail


    Full Time
    Part Time
    Retired


    Full Time
    Part Time


    FacebookYelpGoogleEncore Launch Loyalty Discount PlanWord of MouthWalk InPPO InsuranceDrive ByMedicaid








    Primary Insurance Information



    SelfSpouse
    ChildOther













    Secondary Insurance Information











    SelfSpouse
    ChildOther





    MEDICAL HISTORY



    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 have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.


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    AspirinPenicillinCodeineLocal AnestheticsAcrylicMetalLatexSulfa drugsOther


    Do you have, or have you had, any of the following?


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    To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.



    CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

    SECTION A: PATIENT GIVING CONSENT (PARENT OR GUARDIAN IF PATIENT IS A MINOR)






    SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

    Purpose of Consent: By ​ signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.

    Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of your Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this consent.

    We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

    You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:





    Right To Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this consent will not affect any action we took in reliance onthis consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.



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