New Patient Registration Form Patient Forms Step 1 of 5 - Patient Information 20% Fred R Dahm DDS Eunku Will Chung DDS MSDPatient Information (Confidential)Name* Last First M.I. Preferred Name Home Address* Apt# City AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSN#* * Male Female Single Married Other Minor Primary Cell Phone*Work#Home#Primary Email address* In case of emergency (name)* relation* Phone#*Name/source of referral/how did you hear about our offices* Person financially responsible:* Phone#*Relationship to patient* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSN#* Primary Dental Insurance InformationDo you have dental Insurance?* Yes No Policy Holder/Subscriber Name:* Relationship to Patient* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSN* ID#* Group#* Dental Insurance Company* (Please provide copy of dental card) Employer* Secondary Dental Insurance InformationDo you have dental Insurance?* Yes No Policy Holder/Subscriber Name:* Relationship to Patient* Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SSN* ID#* Group#* Dental Insurance Company* (Please provide copy of dental card) Employer* I certify that the above information is true to the best of my knowledge.If any of this information changes,I will provide that information to Fred Dahm DDS as soon as possible.I understand that failure to provide accurate insurance in a timely manner may result in being billed for the full fee for any services provided to me.Signature* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Fred R Dahm DDS Eunku Will Chung DDS MSDPatient Medical HistoryPhysician Office Phone#Last Exam MM slash DD slash YYYY Are you under medical treatment now?* Yes No Are you wearing contact lenses?* Yes No Have you ever been hospitalized?* Yes No Are you allergic to or have had reactions to the following?If yes please explain Local anesthetic (ex. Novocaine)* Yes No Are you taking any medications?* Yes No Penicillin or any other antibiotics* Yes No Including non-prescription medication?* Yes No Sulfa drugs* Yes No If yes, what are you taking? Barbiturates* Yes No Have you ever taken Fen-Phen/Redux?* Yes No Sedatives* Yes No Have you ever taken Fosamax,Boniva,Actonel or any cancer medications containing bisphosphonates* Yes No Ibuprofen* Yes No Have you ever used tobacco?* Yes No Aspirin* Yes No Do you use a controlled substance?* Yes No Any metal (e.g. nickel,mercury,etc.)* Yes No Latex rubber* Yes No Other please list : Women Only: Pregnant or trying to get pregnant?* Yes No Taking oral contraceptives?* Yes No Nursing?* Yes No High Blood Pressure* Yes No Stroke* Yes No AIDS/HIV Infection* Yes No Heart Attack* Yes No Diabetes* Yes No Sexually Transmitted Disease* Yes No Heart Disease* Yes No Kidney Disease* Yes No Hay Fever/Allergies* Yes No Heart Murmur* Yes No Liver Disease* Yes No Tuberculosis* Yes No Mitral Valve Prolapse* Yes No Hepatitis/Jaundice* Yes No Thyroid Problem* Yes No Angina* Yes No Recent Weight Loss* Yes No Glaucoma* Yes No Chest Pains* Yes No Emphysema* Yes No Arthritis* Yes No Easily Winded* Yes No Asthma* Yes No Joint Replacement or Implant* Yes No Cardiac Pacemaker* Yes No Respiratory Problems* Yes No Stomach Troubles/Ulcers* Yes No Low Blood Pressure* Yes No Cancer* Yes No Smoker* Yes No Fainting/Seizures* Yes No Radiation Therapy* Yes No Dental Fears* Yes No Rheumatic Fever* Yes No Leukemia* Yes No Mental Disorders* Yes No Epilepsy/Convulsions* Yes No Anemia* Yes No Nervous Disorders* Yes No Patient Dental History Name & office # of previous Dentist Date of last exam MM slash DD slash YYYY Do your gums ever bleed while brushing or flossing* Yes No Do you have frequent headaches* Yes No Do you ever have bad breath or a funny taste in your mouth* Yes No Do you clench or grind your teeth* Yes No Have you ever had scaling & root planing (deep cleaning)* Yes No Do you bite your lips or cheeks frequently* Yes No Are your teeth sensitive to sweet or sour liquids/foods* Yes No Do you feel pain to any of your teeth* Yes No Are your teeth sensitive to hot or cold liquids/foods* Yes No Are any of your teeth loose* Yes No Have you ever had difficult extractions in the past* Yes No Do you have any sores or lumps in or near your mouth* Yes No Any prolonged bleeding after a tooth extraction* Yes No Do you wear dentures or partials* Yes No Have you had any neck or jaw injuries* Yes No Do you have a dry mouth* Yes No Have you ever experienced any of the following problems:Have you put off dental care out of fear* Yes No Clicking* Yes No Would you consider your teeth to be in good health now* Yes No Pain (joint, ear, side of face)* Yes No Do you like your smile* Yes No Difficulty in opening, closing or chewing* Yes No Have you ever had any orthodontic treatment* Yes No ***I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and records of any treatment or examination rendered to me or my children during the period of such dental care to third party payors and /or health practitioners. I authorize and request my insurance company to pay directly to the dentist insurance benefits for the payment of all services rendered on my behalf or dependents.***Signature of patient (or parent guardian if a minor)* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Fred R Dahm DDS Eunku Will Chung DDS MSDFinancial AgreementGENERAL : Payment of the patients estimated portion is due at the time of scheduling or at the time of service (you will be informed which is required at the time the estimate is provided). This amount includes, but not limited to, patient portions, deductibles and co-payments. Insurance contributions are estimated as a courtesy, however, are in no way a guarantee of coverage. In the event that your insurance carrier contributes less than what we have estimated, then you, the patient and/or guarantor, is responsible for any unpaid balance. Pre-determinations are performed upon request, however, are still not a guarantee of payment from insurance. We accept cash, check, all major credit cards, and Care Credit on approval of credit. INSURANCE :Please remember that your insurance policy is a contract between you, your employer and insurance company. Not all services are covered benefits in all dental contracts. It is your responsibility, as the patient, to review and familiarize yourself with your insurance’s common coverage and limitations, as it is an agreement between you and your insurance company.Our team will do our best to assist you with your insurance policy, however it is ultimately your responsibility to keep track of benefits and remaining benefits throughout the benefit year. We must emphasize that as dental care providers, our relationship is with you, not your insurance. While the filing of insurance is a courtesy that we extend to our patients. All charges are your responsibility from the date services are rendered. CANCELLED or MISSED APPOINTMENTS : Please kindly give 48 hours advance notice if you cannot keep your reserved or prescheduled appointment. There is a $50 (per hour of time set aside for appointments) fee that may be applied for less than proper notice. If you are late to an appointment, please understand that your appointment may be shortened or rescheduled. CHECKS RETURNED & NSF:There is a $40 charge for check returns and NSF per incident. FINANCE CHARGE:Outstanding balances over 30 days are subject to a 1.5% per month,18% annual interest charge. Outstanding balances over 90 days may be subject to collection company referral and fees. PATIENT AUTHORIZATION: I have read, understand, and agree to the terms and conditions of this financial agreement. I agree to abide by the terms of these policies. I authorize this office to release information, relating to my dental care, to my insurance company and authorize payment of benefits to be made to Fred Dahm Dentistry -DBA F. R. Dahm D.D.S. P.L.L.C. I understand and agree that regardless of my insurance status, I am ultimately responsible for the balance on my account. I authorize and give consent for dental treatment of the patient named above and agree to pay all fees and charges for such treatment and services rendered. I understand as the parent and/or legal guardian of the minor receiving dental care at this office, I am ultimately responsible for all payments or fees for dental services rendered to the minor in my care. I agree that this authorization shall remain valid until cancelled by me in writing.Patient Signature (Parent or Legal Guardian)* Reset signature Signature locked. Reset to sign again Date* MM slash DD slash YYYY Print Name (Parent or Legal Guardian)* Date* MM slash DD slash YYYY Fred R Dahm DDS Eunku Will Chung DDS MSDNOTICE OF PRIVACY PRACTICESTHIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US OUR LEGAL DUTY Dentist may be required by applicable federal and state law to maintain the privacy of your health information and provide notice of their legal duties and privacy practices for health information. Protection of patient privacy is important to Fred Dahm Dentistry. This notice summarizes the privacy practices that will be followed by our office and staff, and your rights concerning your health information. This Notice will apply to all health information collected. You may request a copy of our Notice at any time. For more information about our privacy practices, of for additional copies of this Notice, please contact us using the information listed at the end of this Notice. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment. For example, we may use or disclose your health information to another dentist, physician or other health care provider providing treatment to you. We may use and disclose health information about you for health care operations, such as quality assessment and improvement. Your Authorization:Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. To Your Family and Friends:We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person involved in your treatment to the extent necessary to help with your healthcare. Persons Involved In Care:We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required by Law:We may use or disclose your health information when we are required to do so by law. Abuse or Neglect:We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal official’s health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances. PATIENT RIGHTS Access:You have the right to look at or get copies of your health information, with limited exceptions. Contact us using the information listed at the end of the Notices for assistance in reaching the dentist or facility holding your health information. Disclosure Accounting:You may have the right to receive a list of instances in which your health information was disclosed for purposes other than treatment or certain other activities for the last 6 years, but not before April 14, 2003. Restrictions:You may request that we place additional restrictions on our use or disclosure of your health information. In most cases we are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication:You may request that we communicate with you about your health information by alternative means or to alternative locations. We may agree to reasonable requests. Amendment:You may request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. Fred R Dahm DDS Eunku Will Chung DDS MSDAcknowledgement of Privacy PracticesMy signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to: Provide and coordinate my treatment among a number of healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers for my healthcare services. Conduct normal healthcare operations such as quality assessment and improvement activities. I have been informed of my dental providers Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my provider has a right to change the Notice of Privacy Practices and that I may contact this office at the address below to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations and I understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.Signature* Reset signature Signature locked. Reset to sign again Patient Name:* Date* MM slash DD slash YYYY Dependent family members also covered by this acknowledgement:*File Upload Drop files here or Select files Accepted file types: jpg, gif, png, pdf, xlsx, xls, jpeg, doc, docx, txt, Max. file size: 50 MB.
