New Patient Form Step 1 of 4 25% Patient NameDate of BirthAgeSexSocial Security Number(Required)Address Street Address City State / Province / Region ZIP / Postal Code PhoneEmail Address If Minor, Legal Guardian's NameEmergency ContactEmergency Contact NumberRelationshipOk to share appointment info Yes No In the event our dentists prescribe medication, what is your pharmacy of choice?Preferred Pharmacy NamePharmacy NumberComplete the following if you would like us to submit claims to your dental insurancePrimary Dental InsuranceSecondary InsuranceHow did you hear about our office?(please check all that apply) Patient PWD Staff Doctor FaceBook/Instagram/Tiktok Internet Drive-By Spanish or Radio Other OtherPrimary Reason for your visit with us todayDental HistoryName of previous dentistPrevious dentist's location Street Address Date of last exam Date of last cleaning I certify that the information I provided is correct. I understand payment is required for all services at the time they are rendered. Our terms are net 30 days. Late charges of 1.5% per month (18% APR) will be assessed on past due accounts, and collection charges and/or attorney fees may be added. Appointments that are not canceled 48 hours prior to the appointment time may be charged a $50 fee. Your signature below signifies your understanding and willingness to comply with this policy.Insurance: I understand that my insurance is a contract between my insurer and myself. I am responsible for understanding the terms of my policy, including deductibles, copays, and coinsurance. All applicable co-payments and deductibles will be collected at the time of service. I authorize the release of medical information necessary to process insurance claims to insurance companies of their agencies, for the purpose of filling and payment of dental claims. I authorize payment of dental benefits to Oscar Hernandez Jr., DMD or Parkwood Dental. I understand that ultimately it is the patient's responsibility to keep up with all of their insurance benefits and changes that may take place. Parkwood Dental cannot and does not guarantee payments from insurance companies.Signature of Patient or Legal GuardianDate Patient NameDate of BirthAgeToday's DateMedical HistoryAre you under medical treatment now? Yes No If yes, for whatUntitledHave you been hospitalized for any surgical operation or serious illness within the last 5 years? Yes No If yes, please explainList all medication you are currently taking, including over the counter medications, vitamins, and natural or holistic remedies. Include dose and how often you take itHave you ever needed to take pre-medication (antibiotics) before dental treatment? Yes No Please list all Allergies to MedicinesMedicationReaction Add RemovePlease check any medical conditions you had or currently are experiencing (attach sheet if necessary)Untitled Anemia Asthma Chest Pains/Angina Epilepsy Glaucoma Heart Murmur High Blood Pressure/Low BP Liver Disease Pacemaker Rheumatic Fever Stroke Tumors Untitled Arthritis Blood Disease Diabetes Emphysema Heart Injury Hepatitis Jaundice Mental Disorders Radiation Therapy Sinus Problems Thyroid Problem Ulcers Untitled Artificial Joints Cancer Dizziness Fainting Heart Disease HIV/AIDS/STD Kidney Disease Nervous Disorders Respiratory Problems Stomach Problem Tuberculosis Other Are you taking any medication for bone density/biphosphonates? Yes No Social HistoryDo you smoke? Yes Former No If yes, how many packs per day?Do you chew tobacco?Do you chew tobacco? Yes No Do you drink?Do you drink? Yes Former No Women ONLYAre you pregnant/nursing? Yes No Maybe pregnant Are you on Birth Control?Are you on Birth Control? Yes No How often do you brush your teeth?How often do you floss your teeth?When was your last dental cleaning?History of deep cleaning?Do your gums bleed while brushing or flossing? Yes No Are your teeth sensitive to hot/cold liquids or sour/sweet foods? Yes No Do you feel pain in any of your teeth? Yes No Do you have any sores or lumps in or near your mouth? Yes No Any difficult extractions or prolonged bleeding following extractions? Yes No Do you like your smile? Yes No Do you clench or grind your teeth? Yes No Have you had any head, jaw, or neck injuries? Yes No Have you had any orthodontic treatment? Yes No Do you have frequent headaches? Yes No Do you bite your lips or cheeks frequently? Yes No Have you ever experienced any of the following problems in your jaw? Clicking Pain (joint, ear, side of face) Difficulty in opening or closing Difficulty in chewing Signature of PatientDate Signature of Dental ProviderDate Welcome to Parkwood DentalWe would like to take this opportunity to thank you for selecting us as your personal dental care team. In order to promote a long-term, mutually satisfying relationship we would like to explain our office policy regarding your appointments, treatment and fees.APPOINTMENTSWhen scheduling your appointment(s), the time is reserved exclusively for you. If you fail to notify us of your inability to keep your appointment, it prevents us from treating another patient in need of emergency care and/or treatment. If you are unable to keep your appointment, please notify us 48 hours in advance to avoid a $50.00 fee. If we are unable to confirm your appointment it may be given to another patient in need of treatment that we are able to confirm.TREATMENTYou will find Dr. Hernandez and our entire team dedicated to improving your oral health as quickly and effectively as possible with expert, compassionate care. We will make every effort to make your appointments as comfortable and pleasant as possible. Please feel free to discuss your treatment with Dr. Hernandez, your treatment coordinator, or a member of our team at any time.FEESFor your convenience we accept all major credit cards (Visa/ Mastercard/ American Express/ Discover), debit card, and Cash. In addition, financing options are available. We offer affordable payment options such as Care Credit & Lending Club and a Parkwood Dental preferred in-house no-interest plan. Payment is due at the time services are rendered and will be collected prior to receiving treatment.DENTAL INSURANCEIf you have dental insurance we will be happy to bill your insurance company. However, your deductible, co-payment and any other amounts not covered by insurance are due on the date of services rendered. This may or may not be an accurate amount. Even though an insurance claim has been submitted, you will receive a statement for the remaining balance due. We will attempt to have an estimate of your treatment portion with the information you and your insurance carrier have provided for us. Ultimately it is the patient’s responsibility to keep up with all of their insurance benefits and changes that may take place. Parkwood Dental cannot and does not guarantee payments from insurance companies.The insurance companies determine all benefits. Any claim that is denied immediately becomes responsibility of the patient and prompt payment is expected. I (the patient) am aware that this service is being offered as a courtesy and that I am ultimately responsible for all services rendered. If this account should become delinquent and/or past due, I agree to pay all costs of collection including, but not limited to, court costs, sheriff fees, collection fees, attorney’s fees, and interest from the date of service in the amount of 18% per annum (1.5 % per month). We cannot compromise on your care, but we can do our best to help you get the benefits you deserve. Our office is obligated to provide you with the treatment you need, but your insurance carrier is only obligated to pay what your policy contact calls for.Your confidence and trust in our office is greatly appreciated. Please sign below indicating that you have read and understand the policies of Parkwood Dental.SignatureDate HIPAA Information and Consent FormThe Health Insurance Portability and Accountability Act (HIPAA) provide safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a “friendly” version. A more complete text is posted in our office.We have adopted the following policies:• Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information, which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information. • It is the policy of this office to remind patients of their appointments. We may do this by telephone, email, U.S. mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative. • The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA. • You understand and agree to inspections of the office and review of documents, which may include PHI by government agencies or insurance payers in normal performance of their duties. • You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor. • Your confidential information will not be used for the purposes of marketing or adverting of products, goods or services. • We agree to provide patients with access to their records in accordance with state and federal laws. • We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient. • You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request. I (name below)do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.SignatureDate
