Patient Registration Form Patient Details

Patient Registration Form Contact Information

Patient Registration Form In Case of Emergency

Patient Registration Form Insurance information

(Please give your insurance card to the receptionist)

The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the dentist. I understand that I am financially responsible for any balance. I also authorize Julieta Rodriguez Pasto DMD or insurance company to release any information required to process my claims.

Patient Registration Form Dental History

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Select "Yes" or "No" to indicate if you presently have or previously had of the following:

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Have you experienced:

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HAVE YOU EVER TAKEN ANY OF THE FOLLOWING MEDICATIONS? 

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Patient Registration Form Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrlationship with the treatment you will receive. Your answers are for our records only and will be confidential.

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Women: Are you:

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I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge.

In case that further information is needed you have my permission to ask the respective health care provider or agency, who may release such information to you.

I will notify the dentist of changes in my health and medication.

I hereby authorize the dentist to perform dental treatment, including the use of any necessary or advisable radiographs or diagnostic aids.

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Patient Registration Form Patient Consent for use and Disclosure of Protected Health Information

With my consent, Divine Smile LLC , may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Divine Smile LLC, Notice of Practices for a more complete description of such uses and disclosers.

I have the right to review the Notice of Practices prior to signing this consent. Divine Smile LLC, reserves the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding written request to Divine Smile LLC, Privacy Officer, Dr. Julieta Rodriguez, at 124 Almeria Ave, Coral Gables, FL 33134.

With my consent, Divine Smile, LLC, may call me and leave a voicemail, mail correspondence, and/or e-mail me any items that assist the practice in carrying out treatment, payment collection, appointment reminders, statements, insurance items, and laboratory results. 

By signing this form, I am consenting Divine Smile, LLC, use and disclosure of my protected health information to carry out treatment, payment and healthcare operations. I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent. If I do not sign this consent, Divine Smile, LLC, may decline to provide treatment to me. 

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Patient Registration Form Acknowledgement of Receipt of Notice of Privacy Practices

In order to provide you with the best quality care, we may need to contact you or an authorized person regarding your treatment and/or appointment. Please list who we may contact aside from you regarding these matters.

 

 Who may we share appointment, treatment and financial Information with?

May we contact you at:

May we leave a detailed message at:

I

understand the Privacy Practices.

I understand that if I wish to read the entire Notice of Privacy Practices a copy will be given to me.

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Patient Registration Form Authorization for Dental Treatment

I hereby authorize Dr. Julieta Rodriguez Pasto and his/her associates to provide dental services, prescribe, dispense and/or administer any drugs, medicaments, antibiotics, and local anesthetics that he/she or his/her associates deem, in their professional judgment, necessary or appropriate in my care.

I am informed and fully understand that there are inherent risks involved in the administration of any drug, medicament, antibiotic, or local anesthetic. I am informed and fully understand that there are inherent risks involved in any dental treatment and extractions (tooth removal). The most common risks can include, but are not limited to:

Bleeding, swelling, bruising, discomfort, stiff jaws, infection, aspiration, paresthesia, nerve disturbance or damage either temporary or permanent, adverse drug response, allergic reaction, cardiac arrest.

I realize that it is mandatory that I follow any instructions given by dentist and/or his/her associates and take any medication as directed.

Alternative treatment options, including no treatment, have been discussed and understood. No guarantees have been made as to the results of treatment. A full explanation of all complications is available to me upon request from the dentist.

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Patient Registration Form Consent for Local Anesthetic Injections

I

hereby authorize Dr. Julieta Rodriguez Pasto, DMD to perform a local anesthetic injection(s)

I understand and it has been explained to me that there are some risk in the administration of local anesthetics. Most risks are related to the position of the nerves under the tissue at the site of the injection which cannot be determined prior to the administration of the anesthetic agent. Although the risk seldom occur they might include loss of/or disturbed sensation usually returns in several days. However, in very rare cases the loss of sensation may extend for a longer period and may become permanent. In addition, injecting a foreign substance into the body such as anesthetic agent may result in an allergic reaction. Allergic reactions to these agents are rare but may take place.

I further understand that individual reactions to treatment cannot be predicted, and that if I experience any unanticipated reactions following the injection(s), I agree to report them to the office as soon as possible.

I have been told that the success of my dental treatment depends upon my cooperation in keeping scheduled appointments, following home care instruction, including oral hygiene and dietary instructions, taking prescribed medication and reporting to the office any changes in my health status.

I acknowledge that no guarantees or assurances have been given by anyone as to the results that may be obtained.

I have discussed all the above with the doctor, and have had all my questions answered.

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Patient Registration Form Financial Policy

Our office DOES NOT EXTEND CREDIT. We do not "bill" the patient. We do, however, offer several options for methods of payments so you can choose the one which best suits your personal situation.

- METHOD OF PAYMENT:
1. - Credit Cards: Visa, MasterCard, Discover
2. - Cash
3. - Care Credit, Lending Club (Payment Plan)
4. - Check

B - DENTAL INSURANCE: (Our office cannot be held responsible for our estimate of your benefits) Your estimated Co-Payment is due when treatment is rendered.
IF FOR ANY REASON YOUR INSURANCE COMPANY HAS NOT PAID WITHIN 90 DAYS, THE ENTIRE BALANCE BECOMES DUE AND PAYABLE BY YOU.

ASSIGNMENT OF INSURANCE BENEFITS:
I hereby authorize payment to be made directly to Divine Smile LLC for benefits, which may be due and payable under Insurance coverage for the above named patient. I authorize utilization of this application or copies thereof for the purpose of processing claims and effecting payments. I further acknowledge that this assignment of benefits does not in any way relieve me of liability and that I will remain financially responsible to the above named doctors.

NOTICE OF HIPPA PRIVACY FORMS:
I have read the office's notice of privacy practices.

MISSED APPOINTMENT:
I agree unless my scheduled appointment is cancelled at least 24 hours in advance, that I am liable to pay the broken appointment fee. Please help us serve you better by keeping scheduled appointments.

X-RAY EXAMINATION (FOR FEMALES ONLY):
I am aware that the radiation exposure may be harmful to an unborn child. To the best of my knowledge.
I am not pregnant at the time. I agree to diagnostic x-ray examination as requested by the doctors.

PHOTOGRAPHS AND FILMS:
I further agree to the taking of photographs, films, or other materials showing the condition of my mouth or my treatment for the purpose of documentation, my education or the showing to the public at large or other display of such photographs, films or other materials including dental records, x-rays if necessary for dental, scientific and educational purposes.

THE UNDERSIGNED CERTIFIES THAT HE/SHE HAS READ AND UNDERSTANDS EACH DOCUMENT AND ACCEPTS THESE TERMS. 

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