NEW PATIENTS

Appointment

Patient Information

Personal Information:

Name

First Middle Last

DOB:

Age

Social Security Number

Address

Street Address City State / Province / Region ZIP / Postal Code Country

Wireless Phone:

Home Phone:

Primary Insurance Information:

Insurance Carrier:

Insurance Carrier Phone:

Employer:

Group Number:

Subscriber Name:

Member ID:

DOB

Patient Relationship to Subscriber:

Self

Spouse

Child

Secondary Insurance Information:

Insurance Carrier:

Insurance Carrier Phone:

Employer:

Group Number:

Subscriber Name:

Member ID:

DOB

Patient Relationship to Subscriber:

Self

Spouse

Child

Emergency Contact Information:

Name of Contact:

Phone Number:

Relationship to Patient:

May we communicate information With this individual concerning your care?

Yes

Physician and Pharmacy Information:

Physician Name:

Phone Number:

Street Address:

City/State/Ztp Code:

Date of Last Visit:

Reason for Last Visit?

Pharmacy Name:

Phone Number:

Street Address:

City/State/Ztp Code:

Dental Information:

Prior Dentist Name:

Date of Last Visit?

Date of Last X-rays?

Reason for Today's Visit:

Authorization:

I authorize the dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care.

I attest to the accuracy of the information on this page.

Click to Sign

Date

Privacy Policy | Notice of Information & Privacy Practices | HIPAA Communication Form

By signing this form, you acknowledge that you have received a copy of Professional Dental Alliance practice (“Practice”, “we”, “us”), Notice of Information and Privacy Practices (“Notice”), which describes how your health information is used and shared. You understand that the Practice has the right to change this Notice at any time. You may obtain a current copy by contacting the Privacy Officer at compliance@nadentalgroup.com or by visiting the Practice’s web site.

Patient privacy is important to us. Our policy is to keep patient health information confidential and not disclose such information without your consent or written authorization unless otherwise permitted or required by federal or state privacy laws.

Please provide the names of individuals with whom we can communicate concerning you or your child’s health information and care. This may include family members, friends, organizations, caregivers, and babysitters. This authorization will continue until it is revoked in writing by you. You may revoke this authorization in writing at any time.

Name:

Relationship:

Name:

Relationship:

Name:

Relationship:

Please note: If you have someone accompany you in the treatment area, we will assume this person is entitled to receive information regarding your care and we can freely discuss your health information. If you have a family account, we may share information about your treatment to family members who are part of the family account for payment purposes.

Patient Communication – Our practice is to protect the privacy of our patients while ensuring our patients are kept well informed of their appointments and other information. As a service to our patients, we will communicate appointment reminders and other healthcare related and billing information via text message, email or phone. These messages may come from an automated notification system. Limited information will be left when leaving a voice message. Medical information will not be shared when leaving a voice message. In addition to the aforementioned messages, we will communicate with you through text message from an automated patient notification system regarding your dental bill, surveys regarding your dental care, services or products related to your dental care or other communications related to your dental care and our practice. Please inform our team if you would prefer that we use an additional communication method for appointment reminders or other information related to your care.

Your signature below acknowledges that you have been provided with a copy of the Notice of Information and Privacy Practices and that you authorize the sharing of you or your child’s health information with the individuals listed above. By providing us with your phone number(s) and/or email address, you consent to receive messages, including appointment reminders and other health-care related information by text message, voicemail, and email to the phone number(s) and email address that you have chosen to provide below:

Mobile Phone Number

Home Phone Number

Email Address

Click to sign

Date

NEW PATIENTS

NEW PATIENTS

Appointment

Patient Information

Personal Information:

Primary Insurance Information:

Secondary Insurance Information:

Emergency Contact Information:

Physician and Pharmacy Information:

Dental Information:

Authorization:

Health History Form

Privacy Policy | Notice of Information & Privacy Practices | HIPAA Communication Form

Privacy Policy | Notice of Information & Privacy Practices | HIPAA Communication Form