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New Patient Registration Form (Ages 14+)

New Generation Dental Center

1 Washington Street, Suite 306,
Wellesley, MA 02481
(781) 431-9999

Patient Information( * mandatory to fill )

Please fill in the form below. When you are done, please read the authorizations at the bottom of the form and sign electronically. Questions marked with an asterisk (*) are required

  •  Yes
  •  No
  •  Cell Phone
  •  Home Phone
  •  Email

Emergency Contact Information

Person to contact in case of an emergency

Responsible Party( * mandatory to fill )

Account Information

Person responsible for account (if other than yourself)

Dental Insurance

  •  Yes
  •  No
  •  Check here if you have secondary dental insurance. Please be sure to give us all your insurance information to ensure proper claim filing.
Dental History( * mandatory to fill )
  •  Yes
  •  No
  •  Pain comes and goes
  •  Excellent
  •  Good
  •  Fair
  •  Poor
  •  Yes
  •  No
  •  Amoxicillin
  •  Clindamycin
  •  Cephalexin (Keflex)
  •  Other (please specify)
  •  Smoke
  •  Chew
  •  No
  •  Yes
  •  No
  •  Whiter teeth
  •  Straighter teeth
  •  Healthier gums
  •  Replace missing teeth
  •  Replace chipped/worn teeth
  •  Bad breath
  •  Bleeding while brushing
  •  Bleeding while flossing
  •  Broken teeth/fillings
  •  Burning in mouth
  •  Clicking/popping jaw
  •  Clenching or grinding
  •  Dry mouth
  •  Food gets stuck in teeth
  •  Frequent headaches
  •  Gum surgery
  •  Loose teeth
  •  Mouth breathing
  •  Orthodontic treatment
  •  Pain in jaw joint (TMJ)
  •  Pain when biting
  •  Sensitivity to hot or cold
  •  Sensitivity to sweets
  •  Sores in your mouth
  •  Trauma to mouth/teeth/jaw
Medical History( * mandatory to fill )

Emergency Contact

Primary Care Physician

Preferred Pharmacy

Medical History

  •  Aspirin/NSAIDs
  •  Barbiturates (Sleeping Pills)
  •  Codeine
  •  Dental Anesthetics
  •  Food Dyes
  •  Gluten
  •  Latex
  •  Milk
  •  Nickel
  •  Peanuts
  •  Penicillin
  •  Pine Tar
  •  Sulfa Drugs
  •  Tetracycline
  •  Tree Nuts
  •  Others
  •  ADHD Medication
  •  Antibiotics
  •  Antihistamines
  •  Aspirin
  •  Blood Thinners
  •  Blood Pressure Medication
  •  Chemotherapy
  •  Cold Medicine
  •  Heart Medication
  •  Hormone Replacements
  •  Insulin/Diabetes Drugs
  •  Nitroglycerin
  •  Pain Medication (Tylenol, Motrin, etc.)
  •  Recreational Drugs
  •  Steroids/Cortisone
  •  Thyroid Medication
  •  Tranquilizers
  •  Other
  •  Abnormal Bleeding
  •  Alcohol/Drug Abuse
  •  Alzheimer's Disease
  •  Anemia
  •  Angina
  •  Arthritis
  •  Artificial Bones/Joints Artificial Heart Valves
  •  Asthma
  •  Blindness
  •  Blood Transfusion
  •  Cancer
  •  Colitis
  •  Congenital Heart Defect
  •  Deafness
  •  Diabetes
  •  Difficulty Breathing
  •  Epilepsy
  •  Fainting Spells
  •  Gastric Reflux (GERD)
  •  Glaucoma
  •  Heart Attack
  •  Heart Disease
  •  Heart Murmur
  •  Hemophilia
  •  Herpes/Cold Sores
  •  High Blood Pressure
  •  HIV/AIDS
  •  Kidney Disease
  •  Liver Disease
  •  Low Blood Pressure
  •  Lupus
  •  Migraines/Headaches
  •  Mitral Valve Prolapse
  •  Multiple Sclerosis
  •  Nerve Damage
  •  Osteoporosis
  •  Pacemaker
  •  Parkinson's Disease
  •  Persistent Cough
  •  Psychiatric Problems
  •  Radiation Treatment
  •  Rheumatic Fever
  •  Scarlet Fever
  •  Sleep Apnea
  •  Sinus Problems
  •  Stroke
  •  Thyroid Problems
  •  Tuberculosis (TB)
  •  Ulcers
  •  Vertigo
  •  Other
  •  Taking Birth Control Pills
  •  Pregnant
  •  Nursing
( * mandatory to fill )

Photo Release 

During office procedures, photographs may be taken for educational purposes, such as lectures, professional articles, and presentations. These photos will never show your full face and your name will never be used.

  •  Yes, I do
  •  No, I do not

Authorizations

I affirm that the information I have given is correct to the best of my knowledge. It will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize New Generation Dental Center to release any information to my insurance company and/or healthcare providers.

I understand that both Dr. Birnbaum and Dr. Aaronson are out of network (i.e. non-contracted) providers for all medical and dental insurance plans, and any treatments will be covered at a non-contracted rate. I understand that it is my responsibility to check insurance coverage prior to any treatment. I understand that my insurance carrier may pay less than the actual bill for services.

I agree to be responsible for payment of all services rendered on my behalf and I understand that payment is expected at the time of service, unless other arrangements are made. 

I understand that I must provide at least 24 hours’ notice if I need to cancel or reschedule an appointment. I understand that failure to provide at least 24 hours’ notice will result in a $50 fee for every hour of the broken appointment.

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. This Notice takes effect 01/01/2014, and will remain in effect until we replace it.

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 a 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 other 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, emails, text messages, 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. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. 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, but not before April 14, 2003. 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.

Restriction: 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 OR 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.

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