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Patient Registration Form

Tarpon Shores Dental - Sarasota

544 John Ringling Blvd,
Sarasota, FL 34236

Patient Details( * mandatory to fill )
  •  Full Time
  •  Part Time
  •  Retired
  •  High School
  •  College
  •  Other
  •  Yes
  •  No
  •  Yes
  •  No
Contact Information( * mandatory to fill )
  •  I would like to receive correspondences via e-mail.
DENTAL HISTORY( * mandatory to fill )
  •  Yes
  •  No

Do you have tooth or gum pain with 

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
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  •  No
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  •  No
  •  Yes
  •  No
  •  Yes
  •  No
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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
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  •  no
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  •  no
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  •  no
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  •  yes
  •  no
  •  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
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  •  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) health. It is my responsibility to inform the dental office of any changes in medical status. 

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Current Medication List( * mandatory to fill )
  •  Yes
  •  No
  •  Coumadin
  •  Jantoven
  •  Ibuprofen
  •  Fish Oil
  •  Pradaxa
  •  Plavix
  •  Asprin
  •  Warfarin
  •  Motrin
  •  Vitamin E
  •  Other NSAIDs
  •  Yes
  •  No
  •  Yes
  •  No

Please list all medications you are taking, including non-prescription medications.

(Please include all vitamins and herbal medications)

HiPAA Form( * mandatory to fill )

Patient Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations

 I understand that as part of my health care, the practice originates and maintains paper and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand this information serves as:

* A basis for planning my care and treatment,
* A means of communication among health professionals who contribute to my care,
* A source of information for applying my diagnosis and treatment information to my bill,
* A means by which a third-party payer can verify, that services billed were actually provided,
* A tool for routine healthcare operations, such as assessing quality and reviewing the competence of staff.
* To disclose, as many be necessary, your health information (including HIV-v/AIDS status, drug and alcohol treatment/abuse notes and qualified mental health notes to other healthcare providers and facilities (such as referrals to or consultations with, other healthcare professionals, labs and hospitals) or any others as may be required by law or court order concerning your treatment payment and /or healthcare.
* To request from another healthcare entity and/or healthcare providers (ie doctors, dentists, hospitals, labs, imaging centers etc) specific healthcare information we may need for planning your care and treatment.

I have been provided the opportunity to review the "Notice of Patient Privacy Information Practices" that provides a more complete description of information uses and disclosures. I understand that I have the following rights:

* The right to review the "Notice" prior to acknowledging this consent,
* The right to restrict or revoke the use or disclosure of my health information for other uses or purposes, and
* The right to request restrictions as to how my health information may be used or disclosed to carry out treatment,

Restrictions

 

I request the following restrictions on the use or disclosure of my health information

May discuss treatment, payment, or healthcare operation with the following persons:

  •  Spouse
  •  Your Children
  •  Relatives
  •  Others
  •  Parents

Messages or Appointment Reminders (Please check all that apply)

Messages will be of a non-sensitive nature, such as appointment reminders.

  •  At home
  •  At work
  •  Do not leave a message
  •  Yes
  •  No

Financial Agreement

I understand that the undersigned individual is obligated (him/her) and guarantees prompt payment of all charges for services rendered to the patient when not covered by insurance carriers or others. Payment of any, unpaid balance is due within 90 days of the final billing. Finance charges may begin to accrue at the maximum rate by law. In addition, such balances may be turned over for collection activity, at which time the undersigned shall be liable for attorney's fees and /or collection agency fees and expenses. The undersigned understands that Tarpon Shores Dental has the right to examine credit bureau files for financial information regarding the collection of unpaid debit. 

 

I fully understand and accept the information provided by this consent.

  •  Yes
  •  No
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