Patient Registration Form Patient Details

Patient Registration Form Contact Information

  •  Yes
  •  No

Patient Registration Form If patient is minor, we need

Patient Registration Form Emergency Contact Information

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Patient Registration Form DENTAL INSURANCE INFORMATION (Primary Carrier)

Patient Registration Form medical history

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DO YOU HAVE or HAVE YOU EVER HAD: YES NO

  •  Yes
  •  No
  •  aspirin, ibuprofen, acetaminophen, codeine
  •  penicillin
  •  erythromycin
  •  tetracycline
  •  sulfa
  •  local anesthetic
  •  fluoride
  •  metals (nickel, gold, silver
  •  latex
  •  other
  •  Yes
  •  No
  •  Yes
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  •  Yes
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ARE YOU:

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

List all medications, supplements, and or vitamins taken within the last two years

Ask for an additional sheet if you are taking more than 6 medications.

PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.

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Patient Registration Form Acknowledgment of Receipt of Notice of Privacy

This consent form allows Grand Dental Studio to use and disclose information about me protected under the Health Insurance Portability and Accountability Act of 1996. This information may be used or disclosed to carry out treatment, payment or health care operations.

Grand Dental Studio has provided me with a Notice of Privacy Practices, which more completely describes such uses and disclosures. It provided this notice prior to my signing this form in accordance with my right to review its practices before signing consent.

I understand that the terms of the Notice of Privacy Practices may change and that I may obtain revised notices by contacting the Privacy Officer at Grand Dental Studio.

I understand that at any time I have the right to revoke this consent provided that I do so in writing, but that Grand Dental Studio may still use information to complete any actions that it began prior to my revoking consent and which rely on my protected health information. I understand that Grand Dental Studio may refuse service if I revoke this consent.

I understand that I have the right to request — now and in the future — how protected health information is used or disclosed to carry out treatment, payment and health care operations, and must be provided by me in writing. I understand that while Grand Dental Studio is not required to agree to my requested restrictions if it does agree, it is bound by that agreement.

By my signature below, I affirm the above information.

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(Your IP Address :IP:34.205.93.2 )
(Please click below to draw/upload sign)
(Your IP Address :IP:34.205.93.2 )

I hereby authorize Grand Dental Studio to use unsecured email and mobile phone text messaging to transmit to me the following protected health information: 1) Information related to the scheduling of appointments; and, 2) Information related to billing and payment.

I hereby authorize that Grand Dental Studio may leave messages on my voicemail to confirm appointments, and/or speak with other members of my household and leave messages with them regarding my appointments.

I hereby authorize that Grand Dental Studio may disclose my health information to any person(s) who accompany me to my appointment, and are present with me in the office while I meet with my dentist and staff.

I hereby authorize that Grand Dental Studio may disclose my personal health information to the person who I have listed as my emergency contact.

I hereby authorize that Grand Dental Studio may disclose my personal health information to the following person(s).

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