New Patient Form

Welcome

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we’ll be glad to help you.We look forward to working with you in maintaining your dental health.

    Patient Information

    Name




    Soc. Sec#

    Address

    City

    State

    Zip

    Home Phone

    Cell Phone

    Email

    Sex

    Age

    Date of Birth


    Patient Employed by

    Occupation

    Business Address

    Business Phone

    Business Email

    Whom may we thank for referring you?

    Notify in case of emergency

    Home Phone

    Cell Phone

    Business Phone

    Email

    Primary Insurance

    Person Responsible for Account




    Relation to Patient

    Date of Birth

    Soc. Sec. #

    Address (if different from patient)

    Home Phone

    City

    State

    Zip

    Cell Phone

    Email

    Person Responsible Employed by

    Occupation

    Business Email

    Insurance Company

    Phone

    Insurance Email

    Contract #

    Group #

    Subscriber #

    Name of other dependents under this plan


    Additional Insurance

    Is patient covered by additional insurance?

    Subscriber Name

    Relation to Patient

    Date of Birth

    Address ( if different from patient )

    Soc. Sec. #

    City

    State

    Zip

    Home Phone

    Cell Phone

    Email

    Subscriber Employed By

    Business Phone

    Business Email

    Insurance Company

    Phone

    Insurance Email

    Contract #

    Group #

    Subscriber #

    Name of other dependents under this plan


    Dental History

    What would you like us to do today

    Are you in dental discomfort today?

    Former Dentist

    Address

    Dentist's Email

    Phone

    Date of last dental care

    Date of last x- rays

    check () yes or no if you have had problems with any of the followings:

    Bad breath

    Food collection between teeth

    Periodontal treatment

    Sensitivity to sweets

    Bleeding gums

    Grinding or clenching teeth

    Sensitivity to cold

    Sensitivity when biting

     Clicking or popping jaw

     Loose teeth or broken fillings

     Sensitivity to hot

     Sores or growths in mouth
    How often do you brush?

    Floss?

    Have do you feel about the appearance of your teeth?

    Have you ever experienced an adverse reaction during or in conjunction with a medical or dental procedure?

    Other information about your dental health or previous treatment


    Medical History

    Physician's name

    Phone

    Address

    Email

    Date of last visit

    Have you had any serious illnesses or operations?

    if yes, describe

    Are you currently under physician care ?

    if yes, describe

    Have you ever had a blood transfusion?

    if yes, give approximate date

    Have you ever taken Fen- Phen / Redux? 

    Women : Are you pregnant? 

    Nursing?

    Taking birth control pills? 

    Check() yes or no whether you  have  had any of the following: 

    AIDS / HIV Positive 

    Cough, persistent 

    High blood pressure

    Shingles

    Anaphylaxis

    Cough up blood

    Jaw pain

    Shortness of breath

    Anemia

    Diabetes

    kidney disease or malfunction

    Skin rash

    Arthritis , Rheumatism

    Epilepsy

    kidney disease or malfunction

    Spina Bifida

    Artificial heart valves

    Fainting

    Liver disease

    Stroke

    Artificial joints

    Food allergies

     Material allergies (latex, wool metal, chemicals)

     Surgical implant

     Asthma

     Glaucoma

    Rheumatic / Scarlet fever

     Swelling of feet or ankles

     Atopic (allergy prone)

     Headaches

     Mitral valve prolapse

     Swelling of feet or ankles


     Back Problems

     Heart murmur

     Nervous problems

     Thyroid disease or malfunction

    Chemotherapy

    Radiation Treatment

    Ulcer / Colitis

     Blood disease

     Heart problems 

     Pacemaker / Heart Surgery

     Tobacco habit
     Describe

     Cancer


     Psychiatric care

     Tonsillitis

    Chemical dependency

    Hemophilia Abnormal bleeding

    Rapid weight gain or loss

    Tuberculosis

    Circulatory problems

    Herpes

    Respiratory disease

    Venereal disease

    Cortisone treatments

    Hepatitis
    Is patient currently taking any medications? If yes, list all
    Does patient have drug allergies? If yes, list all:


    Authorization

    I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there is any change in my medical status, I will inform the dentist.

    I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

    I authorize the dentist to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance.

    Signature
    Date
    Payment is due in full at time of treatment, unless prior arrangements have baan approved.


    • Patient Name
    • Patient ID Number
    • Date of Birth

    Notice of Privacy Practices

    This Notice of Privacy Practices describes the ways in which medical information about you may be used and disclosed, and how you can obtain access to it. Please review it carefully.

    Understanding Your Health Information Each time you visit a dentist or other health care provider, a record of your visit is made in order to manage the care you receive. Vita Dental understands that the medical information that is recorded about you and your health is personal. The confidentiality of your health information is also protected under both state and federal law.

    This Notice of Privacy Practices describes the ways that Vita Dental may use and disclose your information and the rights that you have regardingyour health information. The Notice applies to all Vita Dental.It also applies to dentists and dental auxiliaries at Vita Dental.

    Our Responsibilities

    We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to 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 effect. This Notice takes effect (12/18/2011). and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provide such changes are permitted by applicable law.

    We reserve the right to make changes in our privacy practices and in the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the 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 additional copies of the Notice, please contact Ma Dental.

    Uses and Disclosures of Health Information

    We may use or 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 providers pending treatment to you.

    Payment: We may use or disclose your health information to obtain payment for services we provided to you.

    Healthcare Operations: We may use or disclose your health information in connection with our healthcare operations. Healthcare operations includes quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, and certification licensing or credentialing activities.

    Our 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 to disclose it to anyone for any purpose. If you give us authorization, you may revoke it in writing at any time. Your revocation will not affect any use of 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 note.

    To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of the Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for you 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 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, then 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 emergency circumstances. we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in you healthcare. We will also use our professional judgment and our experience with common practice to make responsible inferences of your best interest in allowing a person to pick up filled prescriptions. medical supplies, x-rays, or forms of health information.

    Marketing Health-Related Services: We will not use your health information for marketing communications without your written 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 are a possible victim of abuse, neglect, or domestic violence or the possible victim 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 safety of others.

    National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose the authorized federal officials health information required for lawful intelligence, counter intelligence. and other national security activities. We may disclose to correctional institution or law enforcement officials having custody of protected health information of inmate 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).

    Signature
    Date

    • 1799 N. Fry Rd
    • Katy, TX 77449
    • (713) 714-4143

    NO SHOW AND CANCELLATION POLICY

    Cancellation of an Appointment

    In order to be respectful of the medical needs of our Community, please be courteous and call promptly if you are unable to attend an appointment. This time will be relocated to someone who is in urgent need of treatment. This is how we can best serve the needs of our Community. If it is necessary to cancel your scheduled appointment, we require that you call 24 hours in advance. Appointments are in high demand, and your early cancellation will give another person the possibility to have access to timely dental care.

    How to Cancel Your Appointment

    To cancel appointments, please call (713) 714-4143. If you do not reach the receptionist, you may leave a detailed message on the voicemail which is revised daily.

    Late Cancellations

    will be considered as a "no show"

    No Show Policy

    A "no show" is someone who misses an appointment without cancelling it 24 hours prior to their scheduled appointment. No-shows inconvenience those individuals who need access to dental care in a timely manner. A failure to present at the time of a scheduled appointment will be recorded in your chart as a "no show". The first time there is a "no show", you will be sent a letter or receive a phone call alerting you to the fact that you have failed to show up for an appointment and did not cancel the appointment. A copy of the letter will be placed in your file. If there is a second "no show", a fee of $75 will be billed to your account. This fee covers administrative tasks associated with your appointment. This fee will need to be paid in full before or on your next scheduled appointment. Please sign that you have read, understand, and agree to this Cancellation and No show policy.


    Patient Name (Printed)


    Date of Birth


    Signature of Patient or Guardian

    Today's Date