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Patient Registration Form

North Central Family Dentistry

5225 N Central Ave #102,
Phoenix, AZ 85012
6022422576

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Primary Insurance Details( * mandatory to fill )

Please show insurance card to the receptionist

Secondary Insurance( * mandatory to fill )

Please show insurance card to the receptionist

Dental history( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
Medical History( * mandatory to fill )

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

  •  yes
  •  no
  •  Yes
  •  No
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  •  Pregnant/trying to get pregnant?
  •  Nursing?
  •  Taking oral contraceptives?
  •  Aspirin
  •  Pencillin
  •  Codeine
  •  Acrylic
  •  metal
  •  Latex
  •  sulfa drugs
  •  Local anesthetics
  •  Other
Do you have, or have you had, any of the following?
  •  Yes
  •  No
  •  DK
  •  Unsure
  •  Yes
  •  No
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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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Dental Practice Consent Form and Acknowledgement of Receipt of Privacy Notice( * mandatory to fill )

1. I am consenting to examination and treatment by Dentist

2. I understand that if I have dental insurance, they may not cover all of the provided services and I may ultimately be responsible for paying for all or part of this/these service(s). I authorize the payment of submitted insurance claims and/or third party claims be paid directly to the Dentist

3. I authorize North Central Family Dentistry to release my dental records and any other information relating to my care to any person, office or company who may need them for treatment, payment or other health/dental care as outlined in the office's Notice of Privacy Practices.

4. Acknowledgment Receipt of Notice of Privacy Practices: I understand that North Central Family Dentistry may share patient health/dental information for treatment, billing and health/dental operations under the federally mandated Privacy Rules of the Health Insurance Portability and Accountability Act of 1996 (HIPPA). All reasonable efforts will be made to protect the privacy of patient health/dental information, whether it is maintained on paper or electronically, and regardless of how it is communicated.

 

I have received a copy of the Privacy Notice for North Central Family Dentistry

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When a patient is a minor or is unable to give consent, the signature of a parent, guardian, or other representative is required.

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