This form is HIPAA compliant to ensure privacy.

Sharo Fatehi, DDS

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New Patient Registration Form

Patient Information

Title:

Sex:
First Name:

Date of Birth:

Nick Name:
Age:
(calculated after submit)
Middle Initial:
Social Security #:
Last Name:
 

 Email:

 
Street:
Home Tel. #:
City:
Business Tel. #:
State:
Ext.:
Zip:
Mobile Tel#:
Employer Name:
Occupation:
 
Dentist:
Dentist Phone #:
Referred By:
Physician:
For Doctor:
Physician Phone #:
Spouse Name:
 
Emergency Contact:
Home Tel. #:
 Relation:
Work Tel. #:
 
Marital Status:

Have you ever been a patient of our practice?

How were you referred to our office?



Referral Name :

Method of Personal Payment:

Are you a student? 
 School:
Preferred appointment time:
 

Account Responsibility/Insurance Card Holder

Who will be responsible for your account? (if patient is a minor)
 
Title:

Date of Birth:

First Name:

Social Security #:

Middle Initial:
Driver's License #:
Last Name: Home Tel. #
 

Street:

 Mobile Tel. #:

City:

Employer Name:

State:

Emp. Tel. #:

Zip:

(if other) Relation:


Spouse or Guarantor Info (if different from above)

Title:

Social Security #:

First Name:

Tel. #:

Middle Initial:

Mobile Tel#:

Last Name:

Employer Name:

 

Street:

Emp. Tel. #:

City:

Relation:

State:

 

Zip:


Primary Dental Insurance

Employer Name:

Group #:

Emp. Tel. #:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Tel. #:

SSN/ID/Contract #:

Insurance PO Box:    
Relationship to Patient:

Primary Medical Insurance

Employer Name:

Group #:

Emp. Tel. #:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Tel. #:

SSN/ID/Contract #:

Insurance PO Box:    
     Relationship to Patient:

Secondary Insurance

Type of Insurance:

Employer Name:

Group #:

Emp. Tel. #:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Tel. #:

SSN/ID/Contract #:

Insurance PO Box:    
     Relationship to Patient:

General Health

Are you in relatively good health?
Height:
Weight:
Have there been any changes in your general health in the past year?
If yes, please explain:
Are you under the care of a physician?
Date of last visit:
For what are you being treated?
Have you had any illness, operation or been hospitalized in the past five years?
Please list:
Do you have injuries or inflamed areas, growths or sore spots in or around your mouth?
Where:
Do you have a heart valve replacement or vascular graft?
Where:
Is this visit related to an accident?
When was the accident?
Are there conditions that the doctor should be aware of?
Please List:
Do you wish to speak to the doctor privately regarding your conditions?

Conditions  (please  check  all  that  apply)

High / Low blood pressureChest pain / angina
Heart Murmur / Mitral Valve ProlapseIrregular heartbeat
Cardiac pacemakerHeart surgery
StrokeHeart attack(s)
Blood transfusionSwollen ankles, arthritis, or joint disease
Chronic fatigue / night sweatsRheumatic fever
Damaged heart valvesProblems with the immune system
Sexually transmitted diseasesTumor or growth
X-Ray treatment / chemotherapyInfectious mononucleosis
Delay in healingMalignant hyperthermia
HIV/AIDSI smoke
Difficult breathing / other lung troubleBronchitis / chronic cough
Asthma / EmphysemaHay fever / sinus problems
TuberculosisI am on a diet
Thyroid troubleLow blood sugar
DiabetesStomach ulcers
Gallbladder troubleBlood disorder such as anemia
Bruise easilyBleeding tendency (abnormal bleeding)
Mental health problemsHistory of drug / alcohol abuse
Convulsions / epilepsyFainting spells
Kidney trouble / DialysisEye Disease / Glaucoma
Contact lensesHepatitis
Pain & clicking of jaws when eatingProsthetic Joint
Other Medical Issues not listed above

Medication & Allergies

Are you taking any kind of medicine, drugs, or pills?
Please list: (especially for Bone Density i.e. Bisphosphonates)
Have you ever taken diet pills?
Please list:

Are you allergic to or have you ever had an adverse reaction to local anesthetics?
Are you allergic to or have you ever had an adverse reaction to aspirin?
Are you allergic to or have you ever had an adverse reaction to latex?
Are you allergic to or have you ever had an adverse reaction to penicillin?
Are you allergic to or have you ever had an adverse reaction to other medications?
Please list all allergies and adverse reactions that you are aware of below:

Women Only

Is it possible that you are currently pregnant?
Are you nursing?
Are you currently taking birth control medicine?

Family History (please  check  all  that  apply)






Fees and Payment Policy
We will perform an Oral surgical consultation and do the necessary treatment. Any cost associated with the treatment to you will be discussed prior to treatment. If you have dental insurance, it is designed to help pay for part of the cost of your dental treatment. The type of benefits and amount of coverage depend on what contract your employer has chosen and the amount of premiums that are paid. Your insurance coverage can range anywhere from 0-100% (however typically from 60-80%). Our office will attempt to determine your ESTIMATED coverage through information you provide. HOWEVER INSURANCE COMPANIES DO NOT INFORM YOU, NOR US OF THE EXACT COVERAGE UNTIL THE TREATMENT IS COMPLETE AND THE CLAIM IS SUBMITTED. The contract is between you and your insurance company, therefore you will be responsible for any fees not paid for by your insurance company. We will gladly submit your insurance claim. 

I certify that I have read and understand the above. 
I authorize the release of any information necessary to process my dental insurance (if applicable). I also authorize my dental insurance carrier to issue the dental benefits directly to Dr. Fatehi’s office. 
Patient Acknowledgements
I hereby acknowledge that I have been given the right to review this office's Notice of Privacy Practices. (HIPAA) A copy of this notice can be viewed here.

I certify that I have read and understand the above.  I affirm that the information contained in this form and any additional information that I may furnish is true and correct to the best of my knowledge.  I understand the above information is necessary to provide me with dental care in a safe and efficient manner.  I will not hold Sharo Fatehi, DDS or the staff responsible for any errors or omissions that I have made in the completion of this form.

I understand that I may purchase the pain medication and/or antibiotics at the office or receive a prescription and have it filled at my local pharmacy.

  
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