PATIENT REGISTRATION FORM

PATIENT REGISTRATION FORM DETAILS

TODAY'S DATE

FIRST NAME

MIDDLE NAME

LAST NAME

PREFERRED NAME

DATE OF BIRTH

Male

Female

MARITAL STATUS

Single

Married

Divorced

Widowed

SSN

HOME ADDRESS

CITY

STATE

ZIP CODE

HOME PHONE NUMBER

CELL NUMBER

EMAIL ADDRESS

EMPLOYER

OCCUPATION

EMERGENCY CONTACT

RELATIONSHIP TO YOU

PHONE NUMBER

HOW DID YOU HEAR ABOUT US?

OTHER FAMILY MEMBERS WHO ARE PATIENTS HERE

PLEASE CHECK PREFERRED FORM OF COMMUNICATION:

Phone call

Text message

Either

INSURANCE INFORMATION

POLICY HOLDER NAME

BIRTH DATE

SSN

EMPLOYER

BUSINESS PHONE NUMBER

DENTAL INSURANCE COMPANY

GROUP #

MEMBER/SUBSCRIBER ID #

CLAIMS ADDRESS (on back of insurance card)

CITY

STATE

ZIP CODE

SECONDARY INSURANCE INFORMATION (if applicable)

POLICY HOLDER NAME

BIRTH DATE

SSN

EMPLOYER

BUSINESS PHONE NUMBER

DENTAL INSURANCE COMPANY

GROUP #

MEMBER/SUBSCRIBER ID #

CLAIMS ADDRESS (on back of insurance card)

CITY

STATE

ZIP CODE

PERMISSION FOR DENTAL TREATMENT

I give my permission to Alexandra Wetzel, DDS,and/or Dr. Gonzalo Hernandez, DDS, to perform all necessary procedures. In the event that I need treatment, Dr.Alexandra,Dr. Gonzo and/or staff will inform of the different methods of treatment. I understand that there is no guarantee of success or permanence to the treatment. If I have any questions regarding treatment, procedures, or insurance, it is my responsibility to make sure my questions have been answered by Dental Haven or my insurance company prior to signing the proposed treatment plan consent form. I, therefore, understand the above statement and consent to the use of procedures if deemed necessary by Dr.Alexandra or Dr.Gonzo. Dental Haven requests a parent or guardian present for all appointments to children under the age of 18. I understand that if I am not present at my child’s appointment, this may limit what is performed at the appointment.

The patient or guardian is responsible for payment at time of service, unless prior arrangements have been approved.

PAYMENT POLICY

INSURANCE:

In most cases, insurance does not cover the full cost of services. It is designed to reduce your cost, but not to eliminate it completely. Our staff will help you receive the maximum benefit available under your policy. However, please remember you are fully responsible for all fees charged by this office regardless of insurance coverage.

We submit all claims to your insurance company after each appointment. The balance that is not covered by insurance is due on the date of service. The following methods of payment are available:

**Cash or check

**Visa/Mastercard

**American Express

**Discover

**CareCredit

Should you need copies of dental records, there is a $4.00 processing fee for technician time, materials, and postage. If ortho models need to be copied, the fee is $55.00.

Any cancellation without giving 24 hours notice or failure to keep the appointment will result in a charge of $55.00.

I have read and hereby agree that I am ultimately responsible for payment of this account.

General Dental Medical Hx

Name

Date

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

Are you under a physician's care now? if so, yes or no? for

Name of present physician and telephone number

Date of last medical exam

Have you ever been hospitalized or had a major operation?

Have you ever had a serious head or neck injury?

Are you taking any medications, pills, or drugs? If so, please list the names and dosages.

Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?

Do you have a history of mental illness?

Do you currently use tobacco? If so, what kind, amount, and for how long?

Do you have a history of tobacco use? If so, what kind and for how long? When did you quit?

Women: Are you...

Pregnant/Trying to get pregnant?

Nursing?

Taking oral contraceptives?

DENTAL HISTORY

DATE OF LAST DENTAL VISIT

WERE XRAYS TAKEN AT YOUR LAST APPOINTMENT?

DO YOU HAVE ANY CONCERNS OR COMPLAINTS ABOUT YOUR TEETH AND/OR GUMS AT THIS TIME?

ARE YOU HAPPY WITH YOUR SMILE AND THE APPEARANCE OF YOUR TEETH? YES/NO... IF NO, PLEASE EXPLAIN WHY

HAVE YOU EVER HAD AN UNFAVORABLE DENTAL EXPERIENCE? YES/NO... Check For Yes and please explain in the box on the right

ARE YOU APPRENHENSIVE ABOUT DENTAL WORK?

SOMEWHAT

VERY

EXTREMELY

HAVE YOU EVER HAD ANY PROBLEMS GETTING NUMB FOR A DENTAL PROCEDURE? YES/NO... IF YES, PLEASE EXPLAIN

HOW OFTEN DO YOU BRUSH YOUR TEETH?

HOW OFTEN DO YOU FLOSS YOUR TEETH?

PERSONAL HEALTH INFORMATION DISCLOSURE AGREEMENT

I , do hereby grant permission for Dental Haven, S.C., to disclose personal health information to the following personal representatives:

Name:

Relationship:

Information to be disclosed (please check those that apply):

Any pertinent dental health or financial information related to treatment at this office

Appointment dates and times

Treatment plans and referrals

Financial and billing information

Insurance information

I understand that this permission will remain in effect unless a written cancellation has been provided to Dental Haven, S.C.

DO YOU SUFFER FROM OR EXPERIENCE ANY OF THE FOLLOWING: (check all that apply) Check All

LUMPS IN YOUR MOUTH

BLEEDING OR RECEDING GUMS

GRINDING OR CLENCHING

POPPING OR CLICKING OF JAW

DISCOLORED TEETH

CROWDED TEETH

SENSITIVE TEETH

SLEEP APNEA/CPAP MACHINE

To the best of my knowledge, the questions on these forms have been accurately answered. I understand that providing incorrect information can be dangerous to my (or the patient's) health. It is my responsibility to inform that dental office of any changes in medical status.

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain 
rights to privacy regarding my protected health information. I understand that this information may be used for:

                                                                                                                                                                                                                                     
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use or disclose your health information to obtain payment for services provided.
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 qualifications of healthcare professionals, 
evaluating practitioner and provider performance, conducting training programs,accreditation, certification, licensing or credentialing activities.
 
Your authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written 
authorization to use your health information or disclose it to anyone for any purpose.If you give us an authorization, you may revoke it in 
writing at any time. Your revocation will not affect use or disclosures permitted by your authorization while it was in effect. 
Unless you give us written authorization,we cannot use or disclose your health information for any reason except those described in this Notice. 
To Your Family & Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice.We may 
disclose your health information to a family member, friend or other person to the extent necessary to 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 notification of (including identifying or locating) a 
family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If
you are present, prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or
disclosures.In the event of your incapacity or in emergency circumstances, we will disclose your health information based on a determination 
using our professional judgment,disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We 
will also use our professional judgment and our experience with common practices to make reasonable inferences of your best interest in 
allowing a person to pick up filled prescriptions, medical supplies, x-rays or other similar forms of health information.
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 are a possible victim of
abuse,neglect or domestic violence or the possible victims of other crimes. We may disclose your health information to the extent necessary to 
avert a serious threat to your health or safety or the health or safety of others.
National Security: Under certain circumstances, we may disclose to military authorities the health information of Armed Forces personnel. We 
may disclose to authorized federal officials any health information required for lawful intelligence, counterintelligence, and other national 
security activities.We may disclose to correctional institutions or law enforcement officials having lawful, custody protected health information
of inmates or patients 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).

________________________________________________________________________________________________________________________________________
Your signature below indicates that to the best of your knowledge, all information entered in the patient registration and medical history 
portion of this document is accurate and up to date.Your signature below indicates that you agree to our dental treatment and payment policies.
Furthermore, your signature below indicates that you understand Dental Haven’s compliance with the federal HIPAA laws.
If you’d like a full copy of HIPAA, please ask a member of the Dental Haven Staff.
________________________________________________________________________________________________________________________________________

Patient Name:

Signature:

DATE

Relationship to Patient (if Applicable):