NEW PATIENT FORM






Policy HolderResponsible Party


Responsible Party (if someone other than the patient)
















Responsible Party is also a Policy Holder for Patient
Primary Insurance Policy Holder
Secondary Insurance Policy Holder


Patient Information






MaleFemale

SingleMarriedDivorcedSeparatedWidowed








I would like to receive correspondences via e-mail

Full TimePart TimeRetired

Full TimePart Time

Encore Launch Loyalty Discount PlanWord of MouthWalk InDrive ByMedicaid







Primary Insurance Information



SelfSpouseChildOther











Secondary Insurance Information



SelfSpouseChildOther










MEDICAL HISTORY



Although dental personnel primarily treat the area in and around your mouth, your mouth is connected to your entire body. Health problems that you may have or medication that you may be taking could have an important impact on the dentistry you will receive. Thank you for answering the following questions.


YesNo


YesNo


YesNo


YesNo

YesNo



YesNo


YesNo


YesNo


YesNo


YesNo


YesNo

For Women:


YesNo

YesNo

YesNo

Aspirin PenicillinCodeineLocal AnestheticsAcrylicMetalLatexSulfa drugsOther

Do you have, or have you had, any of the following?

YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo
YesNo

YesNo








CONSENT FOR USE AND DISCLOSURE
OF HEALTH INFORMATION

SECTION A: PATIENT GIVING CONSENT (PARENT OR GUARDIAN IF PATIENT IS A MINOR)







SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By ​signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of your notice accompanies this consent. We encourage you to read it carefully and completely before signing this consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our notice, at any time by contacting:





Right To Revoke: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this consent.