PATIENT REGISTRATION
ID:
Chart ID:
Preferred Name:
❑ Policy Holder
Patient Is:
Middle Initial:
Last Name:
[First Name:
❑
Responsible Party
p Responsible Party (if someone other than the patient)
Middle Initial:
Last Name:
First Name:
Address 2:
Address:
Pager:
City, State, Zip:
Ext:
Work Phone:
Home Phone:
Soc Sec:
Birth Date:
Cellular:
Drivers Lic:
0 Responsible Party is also a Policy Holder for Patient 0 Primary Insurance Policy Holder
0 Secondary Insurance Policy Holder
n-Patient Information
Address 2:
Address:
State / Zip:
City:
0 Male
Ext:
Work Phone:
Home Phone:
Sex:
Pager:
Marital Status: 0 Married 0 Single
0 Female
Age:
Birth Date:
Soc. Sec:
Cellular:
0 Divorced 0 Separated 0 Widowed
Drivers Lic:
I would like to receive correspondences via e-mail.
E-mail:
Section 3
Referred By:
Section 2
Employment Status: 0 Full Time
Student Status: 0 Full Time
0 Retired
0 Part Time
Previous Dentist:
0 Part Time
Emergency Contact:
Medicaid ID:
Pref. Dentist:
Employer ID:
Pref. Pharmacy:
Carrier ID:
Pref. Hyg.:
Emergency Contact #:
Physician:
Physicians #:
Prima Insurance Information
Relationship to Insured° Self
Name of Insured:
0 Other
Insured Birth Date:
Insured Soc. Sec:
Ins. Company:
Employer:
Address:
Address:
Address 2:
Address 2:
City,State,Zip:
City,State,Zip:
Rem. Benefits:
0 Spouse 0 Child
.00
Rem. Deduct:
.00
--Secondary Insurance Information
Relationship to Insured:0 Self
Name of Insured:
Insured Birth Date:
Insured Soc. Sec:
Ins. Company:
Employer:
Address:
Address:
Address 2:
Address 2:
City,State,Zip:
City,State,Zip:
Rem. Benefits:
.00
Rem. Deduct:
.00
0 Spouse 0 Child 0 Other
Jack B. Oh, D.D.S.
MEDICAL HISTORY
Birth Date
PATIENT NAME
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.
Are you under a physician's care now? 0 Yes 0 No
Have you ever been hospitalized or had a major operation? 0 Yes 0 No
If yes, please explain:
If yes, please explain:
Have you ever had a serious head or neck injury? Q Yes Q No
Are you taking any medications, pills, or drugs? Q Yes 0 No
If yes, please explain:
If yes, please explain:
Do you take, or have you taken, Phen-Fen or Redux? Q Yes Q No
Have you ever taken Fosamax, Boniva, Actonel or any
u Yes 0 No
other medications containing bisphosphonates?
Are you on a special diet? Q Yes 0 No
Do you use tobacco? Q Yes Q No
Do you use controlled substances? 0 Yes Q No
Women: Are you
Pregnant/Trying to get pregnant? 0 Yes
0
No
Taking oral contraceptives? Q Yes 0 No
Are you allergic to any of the following?
Aspirin
Other
0 Penicillin
El Codeine
0 Local Anesthetics
0 Acrylic
Metal
0 Latex
J Sulfa drugs
If yes, please explain:
•
•
Do you have, or have you had, any of the following'?—
AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
0
0
0
0
0
0
0 Yes 0 No
Epilepsy or Seizures
Excessive Bleeding
Artificial Joint
0 Yes Q No
Excessive Thirst
Asthma
0 Yes 0 No
Blood Disease
Blood Transfusion
0 Yes 0 No
0 Yes 0 No
Fainting Spells/Dizziness0 Yes Q No
Frequent Cough
0 Yes Q No
Frequent Diarrhea
0 Yes 0 No
Breathing Problem
0 Yes 0 No
Frequent Headaches
Bruise Easily
0 Yes Q No
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
0 Yes 0 No
0 Yes 0 No
0
Cancer
0
Chemotherapy
0
Chest Pains
Cold Sores/Fever Blisters
Yes 0
Yes 0
Yes 0
Yes Q
Yes Q
Yes 0
No
No
No
No
No
No
Yes Q No
Yes 0 No
Yes Q No
0 Yes Q No
Congenital Heart Disorder() Yes 0 No
Convulsions
Q Yes Q No
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Heart Trouble/Disease
0 Yes 0 No
Hemophilia
0 Yes 0 No
Radiation Treatments
0 Yes 0 No
0 Yes 0 No
Q Yes Q No
Hepatitis A
Hepatitis B or C
0 Yes Q No
Q Yes 0 No
0 Yes 0 No
Recent Weight Loss
Renal Dialysis
0 Yes 0 No
0 Yes 0 No
0 Yes 0 No
Herpes
High Blood Pressure 0 Yes 0 No
High Cholesterol
0 Yes 0 No
Rheumatic Fever
Rheumatism
Scarlet Fever
0 Yes 0 No i
0 Yes 0 No
Hives or Rash
0 Yes Q No
Shingles
0 Yes 0 No
Hypoglycemia
Irregular Heartbeat
0 Yes 0 No
0 Yes Q No
Sickle Cell Disease
Sinus Trouble
0 Yes 0 No
0 Yes 0 No
Kidney Problems
Leukemia
0 Yes 0 No
Q Yes 0 No
Q Yes Q No
Liver Disease
Q Yes Q No
0 Yes 0 No
0 Yes 0 No
Low Blood Pressure 0 Yes 0 No
Lung Disease
0 Yes 0 No
Mitral Valve Prolapse 0 Yes 0 No
Osteoporosis
0 Yes Q No
Pain in Jaw Joints
0 Yes 0 No
Spina Bifida
0 Yes 0 No
Stomach/Intestinal Disease 0 Yes Q No i
Stroke
Yes Q No
Swelling of Limbs
0 Yes 0 No I
Thyroid Disease
Yes
No
Tonsillitis
Yes
No
Tuberculosis
Yes 0 No
Tumors or Growths
0 Yes 0 No'
Ulcers
0 Yes 0 No 1
Venereal Disease
Yes 0 No
Yellow Jaundice
Yes
No
0 Yes 0 No
0 Yes 0 No
0 Yes 0 No
0 Yes Q No
0 Yes 0 No
Q Yes 0 No
0 Yes 0 No
Parathyroid Disease 0 Yes Q No
Psychiatric Care
Q Yes Q No
0 Yes 0 No 1
0
0
0
0
0
0
Have you ever had any serious illness not listed above? Q Yes 0 No
Comments:
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.
SIGNATURE OF PATIENT, PARENT, or GUARDIAN
DATE
1
1
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
* You May RefUse to Sign This Acknowedgement*
have received a copy of this
office's Notice of Privacy Practices.
•
Please Print Name
Signature
Date
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but
acknowledgement could not be obtained because:
❑
Individual refuSed to sign
❑
Communications barriers prohibited obtaining the acknowledgement
❑
An emergency situation prevented us from obtaining acknowledgement
❑
Other (Please Specify)
47 2002 American Dental Association
All Rights Reserved
Reproduction and use of this form by dentists and their staff is permitted. Any other use. duplication or distribution of this form by any other party requires the prror
written approval of the American Dental Association.
This Form is educational only, does not constitute legal advice. and covers only federal. not state, taw (August 14. 2002).
Dr. Jack Oh, DDS a professional corporation
CONSENT FOR USE AND DISCLOSURE
OF HEALTH INFORMATION
SECTION A: PATIENT GIVING CONSENT
Name:
Address:
E-mail .
Telephone:
Social Security #:
Patient #:
SECTION B: TO THE PATIENT
—
PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether
to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to
read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change
our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those
changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:
Contact Person:
Telephone:
Dr. Jack Oh, DDS
909-444-9400
Fax:
909-444-3311
E-mai..
Address:
2705 S. Diamond Bar Blvd #288 Diamond Bar, CA 91765
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your
revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not
affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to
treat you or to continue treating you if you revoke this Consent.
SIGNATURE
, have had full opportunity to read and consider the
contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent
form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment,
payment activities and health care operations.
I
Date:
Signature:
If this Consent is signed by a personal representative on behalf of the Patient, complete the following:
Personal Representative's Name:
Relationship to Patient:
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.
Include completed Consent in the patient's chart.