Pro Dental Concepts Patient Medical Dental Information Form

Existing Patient
If there is change in any of the following, please check the box*

AddressPhone NumberEmergency Contact InformationPresent InsuranceNo Change
Patient's Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number
Home
Please enter a valid phone number.
Work
Please enter a valid phone number.
Cellular
Please enter a valid phone number.
Emergency Contact
Name

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.
Insurance
Please Specify

Primary InsuranceSecond Insurance
Primary Insurance
Name of Policy Holder

First NameMiddle NameLast Name
Relationship to you
Insurance Company
Employer
Policy Group Number
Birth Date

MonthDayYear
I.D. / Certificate Number
Secondary Insurance
Name of Policy Holder

First NameMiddle NameLast Name
Relationship to you
Insurance Company
Employer
Policy Group Number
Birth Date

MonthDayYear
I.D / Certificate Number
Patient Consent For Electronic Insurance Claim Submission

Please review the following if you would like our office to process your dental insurance claims electronically.
I AUTHORIZE the release, to my dental benefits plan administer and the CDA, information contained in claims submitted electronically. I also AUTHORIZE the communication of information related to the coverage of services described to Dr. Rajan Verma or Pro Dental Concepts. This AUTHORIZATION shall continue in effect until the undersigned revokes the same.
Signature of Patient

Clear
Patient's Name

First NameMiddle NameLast Name
Signature Of Responsible Party

Clear
Responsible Party's Name

First NameMiddle NameLast Name
Date

MonthDayYear
Date

New Patient
Occupation / Employer
What school are you attending?
Patient's Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Telephone
Cellular/Other*
Please enter a valid phone number.
Home
Please enter a valid phone number.
Work
Please enter a valid phone number.
Emergency Contact
Name

First NameMiddle NameLast Name
Phone Number
Please enter a valid phone number.
Referring Dentist / Clinician
Name of Referring Dentist / Clinician

First NameMiddle NameLast Name
What is the main reason for referral?

Insurance Policy Information

Please provide us with your Insurance Benefits Card
Do you have insurance?*

YesNo
Please specify*

Primary InsuranceSecondary Insurance
Primary Insurance
Name of Policy Holder

First NameMiddle NameLast Name
Relationship to you
Insurance Company*
Employer
Policy / Group Number*
Birth Date

MonthDayYear
I.D. / Certificate Number*
Secondary Insurance
Name of Policy Holder

First NameMiddle NameLast Name
Relationship to you
Insurance Company*
Employer
Policy / Group Number*
Birth Date

MonthDayYear
I.D / Certificate Number*
Patient Consent For Electronic Insurance Claim Submission

Please review the following if you would like our office to process your dental insurance claims electronically.
I AUTHORIZE the release, to my dental benefits plan administer and the CDA, information contained in claims submitted electronically. I also AUTHORIZE the communication of information related to the coverage of services described to Dr. Rajan Verma and/or Pro Dental Concepts. This AUTHORIZATION shall continue in effect until the undersigned revokes the same.
Signature of Patient

Clear
Patient's Name

First NameMiddle NameLast Name
Signature Of Responsible Party

Clear
Responsible Party's Name

First NameMiddle NameLast Name
Date

MonthDayYear
Date

	Yes
Anemia
Asthma
Bleeding Disorder
Mental Health (Depression, Anxiety, Stress)
Steroid Therapy
Breathing / COPD / Lung
Fibromyalgia
Stomach / Ulcers / GI
Dental Anxiety
Neurological Disorder / Multiple Sclerosis
Thyroid Disease
Epilepsy / Seizures
Osteoarthritis (e.g., back, hips, knees)
Vertigo / Dizziness
Heart Disease / Vascular
Osteoporosis / Osteopenia
Tuberculosis
Hepatitis / Liver
Immune Deficiency / AIDS / HIV / Transplant
Kidney / Bladder / Prostate / STD
Tuberculosis
Vertigo / Dizziness

HIPAA Privacy Consent Form
PATIENT CONSENT FORM: FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION
Consent for Consultation and Financial Agreement
How Our Office Collects, Uses and Discloses Patients’ Personal Information
By signing the consent section of this Patient Consent Form, you have agreed that you have given your informed consent to the collection, use and/or disclosure of your personal information for the purposes that are listed. If a new purpose arises for the use and/or disclosure of your personal information, we will seek your approval in advance. Our office will not under any conditions supply your insurer with your confidential medical history. In the event this kind of a request is made, we will forward the information directly to you for review, and for your specific consent. When unusual requests are received, we will contact you for permission to release such information. We may also advise you if such a release is inappropriate. You may withdraw your consent for use or disclosure of your personal information, and we will explain the ramifications of that decision, and the process.*

I Understand
I have reviewed the above information that explains how your office will use my personal information, and the steps your office is taking to protect my information. I know that your office has a Privacy Code, and I can ask to see the Code at any time. I AGREE that Pro Dental Concepts and/or Dr. Rajan Verma, can collect, use and disclose personal information as set out above in the information about the office’s privacy policies.*

I Understand
Patient's Signature*

Clear
Patient's Name

PrefixFirst NameMiddle NameLast Name
Responsible Party's Signature*

Clear
Responsible Party's Name

PrefixFirst NameMiddle NameLast Name
Date

MonthDayYear
Date
Hour MinutesAM/PM Option

To the best of my knowledge, I have answered every question truthfully, completely and accurately.*

I Understand
Patient's Signature*

Clear
Patient's Name

PrefixFirst NameMiddle NameLast Name
Responsible Party's Signature*

Clear
Responsible Party's Name

PrefixFirst NameMiddle NameLast Name
Date

MonthDayYear
Date
Hour MinutesAM/PM Option
Should be Empty:

	Yes	No
Heart Attack
Stroke / TIA
Pacemaker
Angina / Chest Pain
Stents Placed
Congestive Heart Failure
Infective Endocarditis / Rheumatic Heart Disease
Prosthetic Cardiac / Heart Valve
Prosthetic Joint Replacement

	Yes	No	Please specify Location
Bleeding Gums
Dental Senstivity
Tooth Pain/Swelling

	Yes	No	Please specify Location
Bleeding Gums
Dental Senstivity
Tooth Pain/Swelling

	Yes	No
Does your child wear any occlusal appliance?
Does your child have any missing teeth?
Did your child have any trauma to jaw or teeth?

	Yes	No	Please specify Location
Bleeding Gums
Dental Senstivity
Tooth Pain/Swelling

Patient Information

Responsible Party's Information

Existing Patient

Phone Number

Emergency Contact

Insurance

Primary Insurance

Secondary Insurance

Patient Consent For Electronic Insurance Claim Submission

New Patient

Telephone

Emergency Contact

Referring Dentist / Clinician

Insurance Policy Information

Primary Insurance

Secondary Insurance

Patient Consent For Electronic Insurance Claim Submission

Medical Health History

If you have a printed medication list, please provide it to the front staff. Thank you.

Dental History

Information Release

Family Member

Medical History

Information Release

Information Release

Information Release

Information Release

Information Release

Information Release

Information Release

Information Release

HIPAA Privacy Consent Form

PATIENT CONSENT FORM: FOR COLLECTION, USE AND DISCLOSURE OF PERSONAL INFORMATION

Consent for Consultation and Financial Agreement

How Our Office Collects, Uses and Discloses Patients’ Personal Information

	Yes	No	Please Specify	Year	Dental Provider
Periodontal
Orthodontic