Patient registration patient information



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Portside Dentistry

351 Hospital Rd, Suite 201

Newport Beach, CA 92663

T: 949-646-7707 F: 949-646-7795




PATIENT REGISTRATION


PATIENT INFORMATION

Today’s Date:____________

Patient Name: First_______________MI____Last____________________Nickname_____________

Home Address: Street_________________________City_____________________State________

Zip ____________E-mail address:__________________________________________________



Phone: Home_______________________ Mobile_________________________________

Social Security Number:______________________Date of Birth:_______________________

Driver’s License #:________________State:_____________________________

Patient Employed By: ____________Occupation:___________Phone:_________

Address: Street _________________City_________________State________Zip_____________

Sex: Male Female

Marital Status:  MinorMarried Single Divorced Separated Widowed

In case of emergency, who should be notified? _________________________________________

Relationship to Patient:___________________Home Phone:_____________Mobile:____________

How did you hear about our practice?_________________________________________________


ACCOUNT INFORMATION

Person Responsible for Account

Name: First ______________________Last___________________________

Relationship to Patient: Self Spouse Parent Other _____

If other than patient:

Date of Birth: _____________

Address: Street___________City ____________State _____Zip ____________

Phone: Home ____________Mobile ______________________

Employer:_______________Occupation______Work Phone ________________

Work Address: Street___________________City__________________State___Zip___________

DENTAL INSURANCE INFORMATION

Primary Insurance Co.: ________________Group #:_____________Subscriber SS #:_________

Name of Subscriber:____________________Subscriber Date of Birth:_________________

Patient Relationship to Subscriber:__________
Secondary Insurance Co.: ______________Group #: _____________Subscriber SS #:_________

Name of Subscriber:_____________________Subscriber Date of Birth:________________

Patient Relationship to Subscriber:__________

HEALTH INFORMATION
Patient Name: First _________________MI ____ Last __________________Date of Birth _________


Circle appropriate answer:
Yes/ No Are you under the care of a physician for anything other than routine care?

If YES, explain __________________________________________________________

Date of last exam? __________ Reason for exam _______________________________

Name of Primary Care Physician__________Phone #:_________Address:___________

Yes/ No Are you allergic to any drugs or medications?

If YES, explain __________________________________________________________


Yes/ No Are you taking any medications, including herbal supplements?

If YES, explain __________________________________________________________

Yes/ No Have you ever been admitted to a hospital or required emergency care?

If YES, explain __________________________________________________________


Yes/ No Are you in pain now?

If YES, explain __________________________________________________________


Yes/ No Have you ever been pre-medicated for dental treatment?

If YES, why? ___________________________________________________________


Yes/ No Do you smoke or chew tobacco?
Women only:

Yes/No Do you suspect or are you pregnant?

If YES, how many months?________
Yes/No Are you taking birth control pills?

Yes/No Are you nursing?




Have you had or do you have any of the following? (Please circle all that apply)
Heart murmur/Mitral valve prolapse Psychiatric or psychological care Gastrointestinal disease

Rheumatic fever Congenital heart disease Neurological disorders

Glaucoma Heart surgery, disease, attack Pacemaker

Nervousness or anxiety Hepatitis Stroke

Fainting/dizzy spells Kidney disease Artificial heart valve

Epilepsy/seizures Liver disease/jaundice Chemotherapy/radiation

Hip or knee joint replacement Asthma/TB/lung disease/Emphysema Blood disease/anemia

Bisphosphonate drug treatments Venereal disease Thyroid disease

Tumors, growths, cancer HIV/AIDS Arthritis/rheumatism

High or low blood pressure Drug or alcohol dependency Diabetes



Use this space or write on back for any additional information or explanations:_________________

DENTAL HEALTH INFORMATION

What is the reason for your visit today? _________________________________________________
Last dental visit:_____________ Last dental cleaning:_________________ Last x-rays:__________
What was done at your last dental visit? _________________________________________________
Previous Dentist: Name:______________________________________________________________

Address:__________________ State:______Zip: _________Telephone:________
How often do you brush your teeth?___________ How often do you floss? ____________________
Do you have any dental problems now? Yes/ No

If YES, please describe______________________________



Have you had or do you have any of the following?

Hot or cold sensitivity Yes No

Sweets sensitivity Yes No

Biting or chewing sensitivity Yes No

Bad breath/bad taste Yes No

Cold sores/blisters/oral lesions Yes No

Bleeding or painful gums Yes No

Loose teeth or change in bite Yes No

Catching food in between teeth Yes No

Discolored teeth Yes No



Have you ever had?

Orthodontic treatment Yes No

Oral surgery Yes No

Periodontal treatment Yes No

Teeth or bite adjusted Yes No

Mouth Guard Yes No

Serious injury to mouth or head? Yes No

If yes, please explain:__________________



Use tobacco in any form?

Yes No


Have your parents experienced gum disease or tooth loss?

Yes No


Are you satisfied with your teeth’s appearance?

Yes No


If not, please explain:____________________

Was your previous dental experience favorable?

If not, please explain:_____________________



Is there anything else about having dental treatment that you would like to discuss with the dentist?

Yes No


If yes, please describe:_________



Have you had or do you have any of the following?

Clicking or popping of the jaw Yes No

Pain (joint, ear, teeth, face) Yes No

Difficulty opening/ closing mouth Yes No

Head/neck/shoulder aches Yes No

Clenching/grinding of teeth Yes No

Bite your lips or cheeks Yes No

Hold foreign objects with teeth Yes No

(Pencils, pipe, fingernails)

Mouth breathe Yes No

Tired jaws, especially in morning Yes No

Snoring/sleeping disorder Yes No



I have answered the aforementioned health questions to the very best of my knowledge. I will advise Dr. Ming Truong or the dental staff of any changes in my health history. I give this dental office consent to release my health information and x-rays relevant to my treatment to my insurance carriers, physicians or dental specialists that I may be referred to. Signature______________________________________Date____________________________

OFFICE POLICIES

We are committed to providing you with the best possible care and helping you achieve your optimum oral health. Toward these goals, we would like to explain your financial and scheduling responsibilities with our practice.
PAYMENT POLICY: Please be prepared for any deductible, co-pay, or other expenses at the time of service. Financial arrangements are discussed during the initial visit and a financial agreement is completed in advance of performing any treatment with our practice. For your convenience, we accept the following forms of payment: cash, check, credit cards, and zero to low interest third-party financing through CareCredit.

DENTAL INSURANCE: Your dental benefit is a contract between you or your employer and the dental benefit plan. Benefits and payments received are based on the terms of the contract negotiated between you or your employer and the plan. We are happy to help our patients with dental benefit plans to understand and maximize their coverage. As a courtesy, we will file your dental insurance claim for you and accept assignment of payment. Some insurance companies recommend a pre-treatment authorization for the dental treatment to be provided. We will attempt to estimate any expenses prior to your visit to our office.

If our estimate of your portion is less than the amount determined by your plan, the amount billed to you will be adjusted to reflect this.



APPOINTMENTS & CANCELLATION POLICY: We reserve an appointment on the schedule for each patient procedure and are diligent about being on-time. Because of this courtesy, when a patient cancels an appointment, it impacts the overall quality of service we are able to provide. To maintain the utmost service and care, we request a 24-hour notice to reschedule an appointment. If you do not show up to a scheduled appointment, there will be a fee of $50 and a deposit to reserve the appointment time again, may be required. To serve all of our patients in a timely manner, we may need to reschedule an appointment if a patient is fifteen minutes late or more arriving to our practice. To reschedule an appointment due to late arrival, a fee of $50 or deposit to reserve the appointment time again, may be required.

E-MAIL COMMUNICATION: Our office uses email for non-urgent communication with our patients including appointment reminders. There is some risk that any individually identifiable health information and other sensitive or confidential information that may be contained in such email may be misdirected, disclosed to or intercepted by, unauthorized third parties. We will use the minimum necessary amount of protected health information in any communication.

Authorizations:

  • I understand that the information I have given today is correct to the best of my knowledge. ___(initial)

  • I have read the above and agree to the financial and scheduling terms. ___(initial)

  • I authorize the release of information necessary to process my dental benefit claims. I hereby authorize payment directly to Dr. Ming Truong for dental services otherwise payable to me. ____(initial)

  • I hereby acknowledge that a copy of this practice’s Notice of Privacy Practices has been made available to me. (separate enclosure) I have been given the opportunity to ask any questions I may have regarding this Notice. ___(initial)

  • I hereby acknowledge that a copy of this practice’s Dental Materials Fact Sheet has been made available to me. (separate enclosure) I have been given the opportunity to ask any questions I may have regarding this Fact Sheet.___(initial)

Patient Signature________________________________________________Date______________________

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