Robert Solow DDS Warner Center Cosmetic Dental

New Patient Form


PATIENT INFORMATION

January 15, 2021

PATIENT NAME:

GENDER:

STATUS:

SPOUSE'S NAME:

DATE OF BIRTH: Age:

SS#: --

Driver's License#:

ADDRESS:   APT. #:  

CITY: STATE: ZIP:  

HOME #: WORK #:

CELL #: E-MAIL:  

We provide all our patients with e-mail and text message appointment reminders. If you wish NOT to receive any of these services please check the box/s below (your e-mail address as well as other personal information is for office use only and will not be shared with third parties.):

EMPLOYER: How long have you been employed with this company?  

EMPLOYER'S ADDRESS:  

CITY: STATE: ZIP:

OCCUPATION:

HOW DID YOU LEARN ABOUT OUR DENTAL OFFICE? (Please check one of the boxes below)

EMERGENCY CONTACT

EMERGENCY CONTACT: RELATIONSHIP:  

HOME #: WORK #:

CELL #: OTHER #:  

YOUR MEDICAL DOCTOR: DOCTOR'S PHONE #:

(If you do not have dental insurance coverage, please skip to the next section)

DENTAL INSURANCE

PRIMARY DENTAL INSURANCE

COMPANY NAME:

Phone #:

STREET ADDRESS:

CITY: STATE: ZIP:

INSURED'S SS#: --

GROUP# (Plan, Local or Policy #):

INSURED'S NAME:

RELATIONSHIP:

DATE OF BIRTH:

INSURED'S EMPLOYER:

SECONDARY DENTAL INSURANCE

COMPANY NAME:

Phone #:

STREET ADDRESS:

CITY: STATE: ZIP:

INSURED'S SS#: --

GROUP# (Plan, Local or Policy #):

INSURED'S NAME:

RELATIONSHIP:

DATE OF BIRTH:

INSURED'S EMPLOYER:

ROBERT M. SOLOW, D.D.S, INC. – DENTAL INSURANCE POLICES

  • I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims. I understand the above information and guarantee this form was completed correctly to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided.
  • I certify that I or my child is covered by insurance and assign directly to Dr. Robert M. Solow all insurance benefits if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the dentist to release all information necessary to secure the payment benefits. I authorize the use of this signature on all my insurance submissions, whether manual or electronic.

YOUR DENTAL INFORMATION

REASON FOR TODAY'S VISIT:

Are you in pain?

If YES, please rate your pain from 1-10:

How long has this pain persisted?

Do you feel nervous about having dental treatment?

If YES, explain:

Name of previous dentist:

Date of last dental exam?:

Date of last dental X-rays?:

Are you interested in learning more about the following? (check all that apply):

ACCOUNT INFORMATION & AUTHORIZATION

PERSON ULTIMATELY RESPONSIBLE FOR ACCOUNT

NAME:

RELATIONSHIP:

BILLING ADDRESS: STE/APT:

CITY: STATE: ZIP:

CELL #: E-MAIL:

CONFIDENTIAL HEALTH HISTORY

MEDICAL HISTORY

Please check and/or fill in the appropriate answer.

  1. Please rate your general health from 1 to 10:
  2. Has there been a change in your health within last year?

    If YES, explain:
  3. Are you being treated by a physician now for a current medical condition?

    If YES, explain:

    Date of last medical exam?

    Reason for exam:

SYMPTOMS

Have you experienced any of the following in the last 3 months? (Please check all that apply)

CONDITIONS

Have you had or do you have any of the following? (Please check all that apply)

CONDITIONS CONTINUED

This information will not be released unless specifically authorized by patient. (Please check all that apply)

 

ALLERGIES

Are you allergic to or have you had a reaction to any of the following? (Please check all that apply)

Please list any other medications or substances you are or may be allergic to:

MEDICATIONS/SUBSTANCES

Are you taking or have you taken any of the following in the last 3 months? (Please check all that apply)

Please list all medications you are currently taking:

WOMEN ONLY

(Please check all that apply)

Are you taking birth control pills?

Are you or could you be pregnant?

Are you nursing?

ALL PATIENTS

(Please check all that apply)

Do you have or have you had any other diseases or medical problems NOT listed on this form?

If YES, explain:  

Have you ever been pre-medicated for dental treatment?

If YES, why:

Have you ever taken Pondimin or Fen-Phen?

If YES, when:

Are you a smoker?

If YES, how much do you smoke per day? How long have you smoked?

ALL PATIENTS-SLEEP ASSESSMENT

(Please check all that apply)

Have you ever been told you stop breathing while asleep?

Have you ever fallen asleep or nodded off while driving?

Have you ever woken up suddenly with shortness of breath, gasping or with your heart racing?

Do you feel excessively sleepy during the day?

Do you snore, or have you ever been told that you snore?

Have you had weight gain and found it difficult to lose?

Have you taken medication for, or been diagnosed with high blood pressure?

Do you kick or jerk your legs while sleeping?

Do you feel burning, tingling or crawling sensations in your legs when you wake up?

Do you wake up with headaches during the night or in the morning?

Do you have trouble falling asleep?

Do you have trouble staying asleep once you fall asleep?

The practice of dentistry involves treating the whole person. If Dr. Solow determines that there may be a medically compromised situation, medical consultation may be needed prior to commencement of dental treatment.

Do you authorize Dr. Solow and/or his staff to contact your physician if necessary?

Physician's Name:

Office phone#:  

ROBERT M. SOLOW, D.D.S, INC. – DENTAL PRACTICE POLICES

  • We invite you to discuss with us any questions regarding our services. We are best able to address your dental needs, desires and concerns when there are open communications to assure mutual understanding between you and our staff.
  • The information that I have given is correct to the best of my knowledge. I understand that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my or my child’s medical status. I authorize the dental staff to perform necessary dental services for me/ my minor/child.
  • Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with our business manager. In the absence of a preexisting financial arrangement, if your account is greater than 90 days past due, you may be held liable for legal fees, collection agency fees, interest charges and any other expenses incurred in collection of your account.
  • In an effort to improve patient scheduling and care, we respectfully request that you advise us of your need to cancel or change your appointment at least 24 hours prior to your reserved time. Please extend this courtesy both to us and to other patients who may benefit from your appointment time. If you find it necessary to change or cancel an appointment at the last minute, there will be a charge of $45.00 for each hour of appointed time. While we understand that unforeseen emergencies and illness may occur, we ask that you consider the value of our time and the needs of other patients.
  • I certify that I have read and understand the above statements of Office Policy and Health History which I completed. I have answered each question accurately and to the best of my knowledge. I will continue to inform this office and staff of any change in my health status and/or medication. I also consent to Dr. Solow’s office using my cell phone to contact me regarding any appointments, insurance information or account matters. Further, I will not hold Dr. Solow, or any other member of his staff, responsible for any errors or omissions that I may have made in the completion of this form.

HIPAA Privacy Rule of Patient Authorization Agreement

Authorization for the Disclosure of Protected Health Information
for Treatment, Payment, or Healthcare Operations ($164.508(a))

I, , (patient's name) understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for future care or treatment. I understand that this information serves as:

  • a basis for planning my care and treatment;
  • a means of communication among the health professionals who may contribute to my healthcare;
  • a source of information for applying my diagnosis and surgical information to my bill;
  • a means by which a third-party payer can verify that services billed were actually provided;
  • a tool for routine healthcare operations such as assessing quality and reviewing the competence of
    healthcare professionals

I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

I understand that as part of my care and treatment it may be necessary to provide my Protected Health lnformation to another covered entity. I have the right to review this facility's notice prior to signing this authorization. I authorize the disclosure of my Protected Health lnformation as specified below for the purposes and to the parties designated by me.

Privacy Rule of Patient Consent Agreement

Consent of the Use and Disclosure of Protected Health Information
for Treatment, Payment, or Healthcare Operations (164.506(a))

I understand that:

  • I have the right to review this facility's Notice of lnformation practices prior to signing this consent;
  • This facility, reserves the right to change the notice and practices and that prior to implementation will mail a copy of any revised notice to the address l've provided if requested;
  • I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that this facility is not required by law to agree to the restrictions requested.
  • I may revoke this consent in writing at any time, except to the extent that this facility, has already taken action in reliance thereon.
  • lt is this facility's procedure to share Protected Health lnformation with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health lnformation for each transaction.

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Signature Certificate
Document name: New Patient Form
lock iconUnique Document ID: 29875ff46570b4f324ae2850c4dd8a3628ae3fb2
TimestampAudit
November 19, 2020 12:45 pm PSTNew Patient Form Uploaded by Robert Solow - info@robertsolowdds.com IP 76.214.69.88