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NEW PATIENT FORMS
www.wellnessdentalcare.net
Welcome to Wellness Dental Care
To help save time when you arrive for your st visit with uswe have created the attached New Patient Forms. (see list below)
Please print a copy of each, carefully ll each out and then bring them to your rst appointment.
Our Doctors and sta will review your information and enter it into our computer systemto establish you as a patient in our practice.
If for some reason you are unable to print these forms,please call our us at: 760-674-4789 and we will mail, e-mail, or fax them to you.
PATIENT INFORMATIONMEDICAL HISTORY
FINANCIAL AND APPOINTMENT POLICYNOTICE OF PRIVACY PRACTICES (HIPAA)
ACKNOWLEDGMENT OF RECEIPT OF PRIVACY PRACTICES (HIPAA)
If you should have any questions or need further assistance please give us call at: 760-674-4789
wellnessdentalcare
620 Alabama St. Redlands, CA 92373Ph: 909-798-5010Fax: 909-798-5069
PATIENT INFORMATION
Name
Address
Sex M
Yes No
Yes No
ale Female
Birthdate
Single Married Widowed Divorced Separated
Patient SS#
Occupation
EMERGENCY CONTACT AND PHONE NUMBER
Name
Phone
Relationship
PHONE NUMBERS AND E-MAIL
Patient: Home
CTexting OK?
Yes NoTexting OK?
ell
Spouse: Home
Cell
DENTAL INSURANCE
Who is responsible for this account?
Relationship to patient
Birthdate of insured
SS# of insured
Address if di erent from patient
Employer
Business Address
Insurance Company
Group #
Names of other dependents under this plan
ADDITIONAL (SECONDARY) DENTAL INSURANCE
Subscriber Name
Relationship to patient
Birthdate of insured
SS# o nsured
Address if di erent from patient
Employer
Business Address
Insurance Company
Group #
Names of other dependents under this plan
DENTAL HISTORY
Reasons for today’s visit
Date of last dental care
What was done?
Please mark all that apply:
Bad Breath Sensitivity to coldBleeding Gums Sensitivity to hotClicking or popping jaw Sensitivity to sweetsFood collection between teeth Sensitivity to bitingGrinding or clenching teeth Sores or growths in mouthLoose teeth or broken lings Periodontal treatment
How often do you brush? Floss?
How do you feel about the appearance of your teeth?
Are you happy with your smile? Yes No
Explain:
Have you ever experienced an adverse reaction during orin conjunction with a medical or dental procedure? Yes No
Explain:
Other information about your dental health or previous treatment
HOW DID YOU HEAR ABOUT WELLNESS DENTAL CARE?
Print Advertising Website/Internet Billboard TV
Radio Referral Insurance Co. Other
Whom may we thank for referring you?
We are pleased to welcome you to Wellness Dental Care, a full service dental practice.Please take a few minutes to ll out this form as completely as you can. If you have any questions,we’ll be glad to help you. We look forward to working with you in maintaining your dental health.
NEW PATIENT FORMS
www.wellnessdentalcare.net
wellnessdentalcare
Musical Preference
Would you like to listen to music during your treatment?
If Yes,
620 Alabama St. Redlands, CA 92373Ph: 909-798-5010Fax: 909-798-5069
Name:
Are you currently under the care of a Physician? .....Yes No
For what reason?
Physician’s name:
Phone:
Address:
When was your last physical exam?
Have you been hospitalized in the past 2 years? ......Yes No
If yes, for what reason?
Do you smoke or use Tobacco? ................................ Yes No
Frequency:
Emergency Contact:
Relationship:
Phone:
HAVE YOU EVER HAD ANY OF THE FOLLOWINGDISEASES OR MEDICAL CONDITIONS?PLEASE MARK YES OR NO FOR EACH
Abnormal Bleeding ............................................. Yes NoAlcohol Abuse ........................................................ Yes NoAllergy to Household Bleach .......................... Yes NoAnemia ..................................................................... Yes NoAngina Pectoris ..................................................... Yes NoArthritis ..................................................................... Yes NoArti cial Heart Valve ............................................ Yes NoArti cial Joints ........................................................ Yes NoAsthma ...................................................................... Yes NoBlood Transfusion .................................................. Yes NoCancer-Chemotherapy ....................................... Yes NoCirculatory Problem ............................................. Yes NoColitis .......................................................................... Yes NoCosmetic Surgery ................................................. Yes NoDiabetes .................................................................... Yes NoDrug Abuse ............................................................. Yes NoEpilepsy-Seizures .................................................. Yes NoFainting Spells/Dizziness ................................... Yes NoFever Blisters-Mouth .......................................... Yes NoFrequent Headaches .......................................... Yes NoGlaucoma ................................................................ Yes NoGrowth on Head or Neck ................................. Yes NoHIV + AIDS ............................................................... Yes NoHay Fever ................................................................. Yes NoHeart Problems .................................................... Yes NoHemophilia ............................................................. Yes NoHepatitis - Type ........................... Yes NoHerpes ...................................................................... Yes NoHigh Blood Pressure ............................................ Yes NoJaundice ................................................................... Yes No
Kidney Problems ................................................... Yes NoLiver Disease ........................................................... Yes NoLow Blood Pressure ............................................. Yes NoMitral Valve Prolapse .......................................... Yes NoPace Maker .............................................................. Yes NoPsychiatric Condition .......................................... Yes NoRadiation Therapy ................................................ Yes NoRespiratory Problems ......................................... Yes NoRheumatic Fever ................................................... Yes NoScarlet Fever ............................................................ Yes NoSinus Problems ...................................................... Yes NoSpecial Diet .............................................................. Yes NoStroke ......................................................................... Yes NoTaken Fen-Phen ...................................................... Yes NoThyroid Problems .................................................. Yes NoTuberculosis ............................................................. Yes NoUlcers .......................................................................... Yes NoVenereal Disease .................................................... Yes NoWeight Loss-Unexplained ................................. Yes No
Other:
ALLERGIESAspirin......................................................................... Yes NoCodeine ..................................................................... Yes NoDental Anesthetics ............................................... Yes NoErythromycin........................................................... Yes NoJewelry ....................................................................... Yes NoLatex ........................................................................... Yes NoMetals ......................................................................... Yes NoPenicillin ..................................................................... Yes NoTetracycline................................................................ Yes No
Other:
FOR WOMEN ONLY:Are you taking Birth Control Pills?................. Yes NoAre you Nursing? .................................................. Yes NoAre you Pregnant? ................................................ Yes No
If yes, number of weeks:Are you receiving Hormone Therapy? ........ Yes NoAre you receiving treatment forOsteoporosis/Osteopenia?.................................. Yes No
Please elaborate on any questions answered yes:
List all medications you are currently taking:
Signature: Date:UPDATES: PLEASE INITAL AND DATE
SDr. ignature: Date:
Initial Here Date Here Initial Here Date Here Initial Here Date Here
Initial Here Date Here Initial Here Date Here Initial Here Date Here
NEW PATIENT FORMS
www.wellnessdentalcare.net
wellnessdentalcare
620 Alabama St. Redlands, CA 92373Ph: 909-798-5010Fax: 909-798-5069
FINANCIAL ARRANGEMENTSDue to the highly specialized treatment that dentists provide, most treatment plans are usuallycomplex. As a result of the amount of time that we invest in your treatment, along with materialand overhead costs, payment is expected in full at the time of service unless other arrangementshave been made in writing. For your convenience, we accept all major credit cards.
If you have dental insurance, we will contact you insurance company for you anddetermine as close as is possible what your portion is to pay on the date of service. Thisinformation is an estimate only and we cannot guarantee its accuracy. After your insurancecompany pays their portion, we will inform you of what balance, if any, is outstanding for youto pay. This amount will be due upon noti cation. Please note that your insurance policy is acontract between you and your insurance carrier. It is your responsibility to understand yourplan bene ts. If for any reason your insurance carrier does not pay within forty- ve days, asallowed by law, the balance will become your responsibility. Any past due balance is subjectto a monthly nance charge. In the unfortunate circumstance that your account becomes morethan 90 days overdue, we will send your account to our collection agency, your account willalso be charged an additional collection fee of $50.00
APPOINTMENT POLICYThe complex nature of your dental treatment requires a series of appointments with explicitamounts of time periods between them to allow us to complete your treatment to the highstandards that we constantly strive to achieve. Once your appointment schedule is determinedit is then coordinated with the dental laboratory in order to achieve a smooth progression ofyour treatment. It is imperative that your appointments be maintained in order, otherwise yourtreatment may be delayed by several months. If you constantly change the dates of yourappointments, this in turn a ects the laboratory schedule of your treatment, and in this eventwe may not be able to complete your treatment in a timely manner.
Should you need to change a scheduled appointment, we would appreciate the courtesyof being informed at least 48 hours in advance. If your appointment is for 2 hours or more, werequire at least 4 working days notice. Due to the large amount of time involved in prosthetictreatment, other patients who may wish to take your appointment time require several daysnotice in order to accommodate their schedules. We reserve the right to charge your accounta missed appointment fee if appointments are not cancelled with su cient notice.
AGREEMENTI understand the nancial arrangements and agree with this payment schedule as a method ofpayment for my treatment. I understand that I am responsible for my total dental cost regardlessof any insurance coverage.
Signature Date
Initial Here
Initial Here
Initial Here
NEW PATIENT FORMS
www.wellnessdentalcare.net
wellnessdentalcare
620 Alabama St. Redlands, CA 92373Ph: 909-798-5010Fax: 909-798-5069
This notice describes how health information about you may be used and disclosed and how you can getaccess to this information. Please review it carefully. The privacy of your health information is important to us.
OUR LEGAL DUTYWe are required by applicable federal and state law to maintain the privacy of your health information. We are also requiredto give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information.We must follow the privacy practices that are described in this Notice while it is in e�ect. This Notice takes e�ect 4/14/2003,and will remain in e�ect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changesare permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms ofour Notice e�ective for all health information that we maintain, including health information we created or received beforewe made the changes. Before we make a signi�cant change in our privacy practices, we will change this Notice and makethe new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additionalcopies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATIONWe use and disclose health information about you for treatment, payment, and healthcare operations. For example:Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.Payment: We may use and disclose your health information to obtain payment for services we provide to you.Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations.Healthcare operations include quality assessment and improvement activities, reviewing the competence or quali�cationsof healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation,certi�cation, licensing or credentialing activities.Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, youmay give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give usan authorization, you may revoke it in writing at any time. Your revocation will not a�ect any use or disclosures permittedby your authorization while it was in e�ect. Unless you give us a written authorization, we cannot use or disclose your healthinformation for any reason except those described in this Notice.To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section ofthis Notice. We may disclose your health information to a family member, friend or other person to the extent necessary tohelp with your healthcare or with payment for your healthcare, but only if you agree that we may do so.Persons Involved In Care: We may use or disclose health information to notify, or assist in the noti�cation of (includingidentifying or locating) a family member, your personal representative or another person responsible for your care, of yourlocation, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we willprovide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergencycircumstances, we will disclose health information based on a determination using our professional judgment disclosing onlyhealth information that is directly relevant to the person’s involvement in your healthcare. We will also use our professionaljudgment and our experience with common practice to make reasonable inferences of your best interest in allowing a personto pick up �lled prescriptions, medical supplies, x-rays, or other similar forms of health information.Marketing Health-Related Services: We will not use your health information for marketing communications without yourwritten authorization.Required by Law: We may use or disclose your health information when we are required to do so by law.Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you area possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose yourhealth information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
CONTINUED ON PAGE 21
NEW PATIENT FORMS
73-260 El Paseo Palm Desert, CA 92260Phone 760-674-4789
Fax: 760-674-4895www.wellnessdentalcare.net
wellnessdentalcare
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certaincircumstances. We may disclose to authorized federal cials health information required for lawful intelligence,counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcemento cial having lawful custody of protected health information o nmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders(such as voicemail messages, postcards, or letters).
PATIENT RIGHTSAccess: You have the right to look at or get copies of your health information, with limited exceptions. You may request thatwe provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably doso. (You must make a request in writing to obtain access to your health information. You may obtain a form to request accessby using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expensessuch as copies and st time. You may also request access by sending us a letter to the address at the end of this Notice.If you request copies, we will charge you $1.00 for each page, $20.00 per hour for sta time to locate and copy your healthinformation, and postage if you want the copies mailed to you. If you request an alternative format, we will charge acost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or anexplanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a fullexplanation of our fee structure.)
Disclosure Accounting: You have the right to receive a list o nstances in which we or our business associates disclosedyour health information for purposes, other than treatment, payment, healthcare operations and certain other activities, forthe last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we maycharge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your healthinformation. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement(except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health informationby alternative means or to alternative locations. (You must make your request in writing.) Your request must specify thealternative means or location, and provide satisfactory explanation how payments will be handled under the alternativemeans or location you request.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and itmust explain why the information should be amended.) We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive thisNotice in written form.
QUESTIONS AND COMPLAINTSIf you want more information about our privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made aboutaccess to your health information or in response to a request you made to amend or restrict the use or disclosure of yourhealth information or to have us communicate with you by alternative means or at alternative locations, you may complainto us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S.Department of Health and Human Services. We will provide you with the address to le your complaint with the U.S.Department of Health and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to lea complaint with us or with the U.S. Department of Health and Human Services.
Contact cer:
Phone: 760-674-4789
Fax: 760-674-4895
E-mail: [email protected]
This form is educational only, does not constitute legal advice, and covers only federal, not state, law.
2
Dr. Sam Kim73-260 El PaseoPalm Desert, CA 92260
You may refuse to sign this acknowledgement
I, , have been o ered a copy of this o ce’s Notice of Privacy Practices.Please print name
Signature Date
You may discuss my dental treatment with:
You may discuss my nances with:
You may leave a message on my hom e voicemail
Please discuss anything relating to my dental treatment or s with:
FOR OFFICE USE ONLYWe 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)
Initial Here
Initial Here
Initial Here
Initial Here
NEW PATIENT FORMS
www.wellnessdentalcare.net
wellnessdentalcare
620 Alabama St. Redlands, CA 92373Ph: 909-798-5010Fax: 909-798-5069
