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Patient Registration Form

Elsabet H. Tekle, DDS

2415 Musgrove Road, Suite 309,
Silverspring, MD, 20904
3013847800

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Responsible Party's Information( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )
Primary Insurance Details( * mandatory to fill )
Medical History( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

MEDICATIONS

ALLERGIES

  •  Aspirin
  •  Acrylic
  •  Latex
  •  Penicillin
  •  Metal
  •  Codeine
  •  Local Anesthetics
  •  Other

Woman

  •  Pregnant
  •  Trying to get pregnant
  •  Nursing
  •  Taking oral contraceptives

HEALTH HISTORY

  •  AIDS/HIV Positive
  •  Alzheimers Disease
  •  Anaphylaxis
  •  Anemia
  •  Angina
  •  Arthritis/Gout
  •  Artificial Heart Valve
  •  Artificial Joint
  •  Asthma
  •  Blood Disease
  •  Blood Transfusion
  •  Breathing Problem
  •  Bruise Easily
  •  Cancer
  •  Chemotherapy
  •  Chest Pains
  •  Cold Sores/Fever Blisters
  •  Congenital Heart Disorder
  •  Convulsions
  •  Cortisone Medicine
  •  Diabetes
  •  Drug Addiction
  •  Easily Winded
  •  Emphysema
  •  Epilepsy or Seizures
  •  Excessive Bleeding
  •  Excessive Thirst
  •  Fainting Spells/Dizziness
  •  Frequent Cough
  •  Frequent Diarrhea
  •  Frequent Headaches
  •  Genital Herpes
  •  Glaucoma
  •  Hay Fever
  •  Heart Attack/Failure
  •  Heart Murmur
  •  Heart Pace Maker
  •  Heart Trouble/Disease
  •  Hemophilia
  •  Hepatitis A
  •  Hepatitis B or C
  •  Herpes
  •  High Blood Pressure
  •  Hives or Rashes
  •  Hypoglycemia
  •  Irregular Heartbeat
  •  Kidney Problems
  •  Leukemia
  •  Liver Disease
  •  Low Blood Pressure
  •  Lung Disease
  •  Mitral Valve Prolapse
  •  Pain in Jaw Joints
  •  Parathyroid Disease
  •  Psychiatric Care
  •  Radiation Treatments
  •  Recent Weight Loss
  •  Renal Dialysis
  •  Rheumatic Fever
  •  Rheumatism
  •  Scarlet Fever
  •  Shingles
  •  Sickle Cell Disease
  •  Sinus Trouble
  •  Spina Bifida
  •  Stomach/Intestinal Disease
  •  Stroke
  •  Swelling of Limbs
  •  Thyroid Disease
  •  Tonsillitis
  •  Tuberculosis
  •  Tumors or Growths
  •  Ulcers
  •  Venereal Disease
  •  Yellow Jaundice
  •  Yes
  •  No

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.

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Financial Agreement( * mandatory to fill )

In an effort to maintain treatment fees at a minimum while maintaining a high level of professional care, we have established the following financial policy for our office. Please feel free to discuss our fees with us at any time. Before any dental treatment is begun, the patient and/or responsible party will receive a consultation regarding treatment plan and cost.

We require payment in full for the portion, not covered by dental insurance, of dental services to be rendered. For procedures that take multiple appointments to complete, payment may be split up over the number of appointments required. Any other financial arrangements shall be made only at the finance manager and/or doctor's discretion. We accept cash, checks, Amex Visa, MasterCard, Discover, and upon request, we can also provide information regarding financial companies to help assist with the cost of your dental procedures such as Care Credit, and Citi Health. Credit applications for such financing options are available upon request.

As a courtesy to our patients with insurance, we will file your insurance claim, allowing you to pay only your deductible and/or estimated co-payment as services are rendered. Please remember that the contract is between you and your insurance company and your total balance in our office is always your responsibility. Please note that we allow 60 days for the dental claim to be paid. We make every effort to give you an accurate estimate of what your portion of our fees will be, based on the information provided to us. However, we have no way to guarantee the actual terms of your policy. If for any reason there is a balance remaining after your insurance company's payment, you will be sent the statement. Any dispute regarding reimbursement or the amount of reimbursement is between you and your insurance carrier. By agreeing to this policy you agree to all such conditions.

We schedule our appointments to provide each patient with our undivided attention. In order to accomplish this, please be advised that you will be charged for cancellations with less than 24 hours notice at the rate of $50.00 for examination/hygiene appointments and $75.00 for dental procedures appointments. Also, note that any type of deposits and/or payments towards the cosmetic cases will not be refunded. Should the patient change their mind for whatever reason during treatment, the patient will be responsible for all costs incurred including lab fees and related costs.

 

An account with an unpaid balance past 60 days will be sent to a collection agency. At that time, you will be responsible for any and all costs incurred in the collection of your debt from the last date of services, such as attorney fees, court fees and any other fees associated with the collection of your debt.

Original records including radiographs are the property of this office. If you desire, we will provide you with a copy of your record or radiographs for a nominal duplication fee of $25.

We appreciate your confidence in choosing our practice. Please do not hesitate to inquire with a staff member should you have any questions regarding this policy.

 

I have read, understood, and agree to the Office Financial Policy stated above.

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Notice of Privacy Practices( * mandatory to fill )

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or 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, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. 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. Unless you give us the written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

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 another person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. 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 officials 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.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters.)

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. 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 have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to 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.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail(e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, You may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Acknowledgment

I, hereby acknowledge that I have read and fully understand the contents of this document, and I have been given the opportunity to ask any and all questions.
**You may refuse to sign this acknowledgment.

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