bethesdadentalhealth.com - Health History and Registration Form

Health History & Registration
Patient's Information
Name
Email
example@example.com
Social Security #
Date or Birth

MonthDayYear
Date
Residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Employer
Occupation
How did you hear about us?
Would you

Like us to file a claim on your behalfFile a claim to your insurance yourself
Policy Holder's Information

(Providing this information doesn’t relieve you from your financial responsibility towards treatments rendered)
Name
Email
example@example.com
Social Security #
Date or Birth

MonthDayYear
Date
Residence

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone
Please enter a valid phone number.
Cell Phone
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Employer
Occupation
Relation to Patient
Dental Insurance Information

(Providing this information doesn’t relieve you from your financial responsibility towards treatments rendered)
Insurance Company
Insurance Company Telephone
Please enter a valid phone number.
Group Number
Subscriber ID Number
Authorization
I authorize and give informed consent to my dental provider to perform agreed upon procedures that is necessary for proper diagnosis and dental care. These may include but are not limited to, diagnostic (radiographs and oral exams), therapeutic procedures, local anesthesia and the use of other medications. I confirm that the information on this page and the medical history are correct to the best of my knowledge. I hereby authorize insurance payments to go directly to the dental office. Should I receive payment from insurance company in error, I will forward that payment to Bethesda Dental Health upon receipt. I understand that I am responsible for the cost of the agreed upon treatment and services rendered regardless of my insurance benefits. I also authorize Bethesda Dental Health to discuss my protected health and account information with the persons listed below:
Name
Relationship
Patient/Legal Guardian/Parent Signature

Clear
Date

MonthDayYear
Date
Dental History
How long has it been since you last saw a dentist?
What did you have done at that time?
What is the reason for today's visit?
Date of last dental x-rays?

MonthDayYear
Date
When was your last dental cleaning?
Do you want whiter teeth?
Is there anything you would like to change about your smile?
Have you been told that you grind your teeth?
Are your facial muscles sore or tense when you wake up?
Are you teeth or gums sensitive?
Do your wear dentures?
How long have you had them?
Medical History

Do you have or ever had?

	Yes	No
Arthritis
Diabetes
Convulsions/Dizzy Spells
Heart Surgery
HIV Positive/AIDS
Sexually Transmitted Diseases
Cancer
High Blood Pressure
Epilepsy
Jaundice/Liver Disease
Kidney Problems/Dialysis
Tuberculosis
Joint Replace (Including Hip)
Rheumatic Fever
Stroke
Heart Murmur requiring premedication
Mitral Valve Prolapse
Hepatitis A, B, C
Asthma/Breathing Problems
Low Blood Pressure
Hyperthyroid/Hypothyroid
Radiation Therapy
Bleeding Disorder

Other
Have you had any reactions to local anesthetics (Novocain)?
Are you allergic to:

AspirinSulfaCodeinePenicillinOther
Are you under the care of a physician?

NoYes, please explain
Are you currently taking any medications (prescriptions or over the counter, i.e., aspirin, birth control pills)?

NoYes, please list all medications
Female Patients
Are you pregnant?

NoYes, due date
Patient's Name
Parent's Name/Legal Guardian's Name
Patient/Legal Guardian/Parent Signature

Clear
Date

MonthDayYear
Date

Financial & Insurance Policies
We are pleased that you have chosen our practice for your dental care. Our goal is not only to treat you, but also to educate you as how to prevent dental disease. Our mission is to provide you the highest quality dental care in a pleasant surrounding as efficiently as possible. Please read and sign the following.

Insurance Policy:
- Your dental insurance is a benefit that you or your employer purchases from an insurance carrier. It is your responsibility to be familiar with restrictions, limitations and deductions that may apply to your plan and whether or not we are participating with your insurance plan. As a courtesy, we will submit claims to your insurance company. You are financially the responsible party for the treatment that is provided to you. Insurance companies never guarantee payment or coverage so your coinsurance may be overestimated or underestimated. Your estimated payment is due at the time of treatment.
- Please keep in mind that the quoted amount of coinsurance is approximated based on the information received from your insurance company which may or may not be accurate. Coverage doesn’t mean that your insurance will pay for your “covered” procedure. All claims that are rejected or adjusted by the insurance company will become your additional responsibility and payable to Bethesda Dental Health immediately.
- If Dr. Sheida Larijani or the associate doctors are not participating with your insurance, payment is expected in full at the time of service unless prior arrangements have been made. We will provide you with statement of services rendered to submit to your insurance carrier once the balance is paid in full.
- All insurance claims not paid within 60 days of date of service are due and payable by you immediately.
Financial Policy:
- We are available for you after hours and on Saturdays if you have an emergency there will be a charge of $395.00 in addition to your treatment fees.
- We offer no-interest financing …Financing is subject to approval by the participating financial group. For your convenience, we accept Cash, Master Card, and Visa.
- Balances over 60 days old will accrue an interest charge of 1.5% monthly or 18% annually . $15.00 monthly late fee will also be added to your statement if payment is not received. If it becomes necessary to refer your account to collection agency, you will be responsible for all expenses including but not limited to court costs, reasonable attorney's fees(40%) and an account service fee of $35.00.
- Returned checks are subject to a $50.00 service charge.
- Broken and cancelled recare appointments are subject to $50.00 per half hour. Fortyeight(business) hour notice is required to avoid such charges.
- Procedures that involve laboratory work i.e. crowns, dentures….If you fail to maintain your appointment for delivery of your case, you are responsible for laboratory fees in full and 50% of all procedure fees.
- Rendered dental services cannot be canceled or returned.
  A minimum of $100 deposit is required for treatments other than routine cleanings at time of scheduling. It is non-refundable if you cancel three(3) business days or less before your appointment.
- All patients under the age of eighteen MUST be accompanied by a parent or legal guardian. A parent or legal guardian MUST remain on site while treatment is rendered.
- Copies of your x-rays and records are available at you request. We require a written request forty-eight hours prior. There is 65 cents charge per page for your records and $18 processing fee for copies of your most recent x-rays.
Signature of Patient

Clear
Date

MonthDayYear
Date

General Consent for Examination and Treatment
I hereby consent to having dental radiographs, clinical examination and performing treatment upon Patient Name by Bethesda Dental Health.
I understand that dental radiographs are necessary diagnostic procedure to allow Dr. Larijani to make good treatment decisions. I have been given the opportunity to ask questions about the nature and purpose of the treatment, alternative treatment, benefits, risk of each and consequences of no treatment. I have the right to refuse treatment. No guarantee, warranty, or assurance has been given to me that any treatment will be successful or to my complete satisfaction. This consent pertains to treatment rendered upon said patient while in the physical office of Bethesda Dental health by Dr. Larijani or her associates.

Photographs

Bethesda Dental Health may take photographs for certain procedures. These photographs are used for planning your treatment, insurance, laboratory, patient education, and advertising purposes. Photographs will not be taken without verbal consent from the patient. All photographs and/or duplications are property of Bethesda Dental Health.

Email and Text Communications

Your email address is for office use only and will not be sold to any advertising agency. Our email communication is one way communication and, therefore, will not allow for conversations between the patient, doctor or staff about treatment or treatment cost. Occasionally, we may use a third party to facilitate this communication.
Do we have your permission to communicate with you through Emails and Text

YesNo
Please sign below if you agree to above and your questions have been answered to your satisfaction.
Signature of Patient or Legal Guardian

Clear
Date

MonthDayYear
Date

Acknowledgement of Privacy Practices
I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:
- Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
- Obtaining payment from third party payers (e.g. my insurance company);
- The day-to-day healthcare operations of your practice.
I have also been informed of, any given right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
Patient Name
Date

MonthDayYear
Date
Signature

Clear
Relationship to Patient
Dependent family members also covered by this acknowledgement
Should be Empty:

Health History & Registration

Patient's Information

Policy Holder's Information

Dental Insurance Information

Authorization

Dental History

Medical History

Female Patients

Financial & Insurance Policies

General Consent for Examination and Treatment

Acknowledgement of Privacy Practices