Patient Sign-in

Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history

Patient Registration( * mandatory to fill )

  Yes    No

Who do we contact in case of an emergency?( * mandatory to fill )

Please select below

Do You Have Primary Insurance?
Yes No
Do You Have Secondary Insurance?
Yes No
I have read the above choices

Primary Insurance Information( * mandatory to fill )

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Elena Shabani, DDS, Inc. or Insurance Company to release any Information.

SIGNATURE
 
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(Your IP Address : )

Secondary Insurance Information( * mandatory to fill )

The above information is true to the best of my knowledge. I authorize my insurance benefits to be paid directly to the physician. I understand that I am financially responsible for any balance. I also authorize Elena Shabani, DDS, Inc. or Insurance Company to release any Information.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Responsible Person for the Bill( * mandatory to fill )

Additional Information

Medical History

Are you a woman?
Yes
No
Are you pregnant?
Yes
No
Are you Nursing
Yes
No
Are you taking birth control pills?
Yes
No
Are you currently under the care of a physician?
Yes
No
Have you had a serious illness/operation/hospitalization in the past 5 years?
Yes
No
Are you currently taking any prescription or OTC medicine(s)? If so, please list all:
Yes
No
Are you allergic to any of the following?
I have answered all the above questions

Medical History

Have you ever had any of the following diseases or problems?

Abnormal Bleeding
Yes
No
AIDS or HIV infection
Yes
No
Anemia
Yes
No
Angina
Yes
No
Artificial / damaged heart valves
Yes
No
Arthritis
Yes
No
Asthma
Yes
No
Autoimmune disease
Yes
No
Bisphosphonate (Fosamax, Actonel, Boniva, Prolia, Reclast) for osteoporosis / Paget's disease
Yes
No
Blood Transfusion
Yes
No
Cancer / chemotherapy / radiation
Yes
No
Cardiovascular disease
Yes
No
Chest Pain
Yes
No
Chronic Pain
Yes
No
Congenital Heart Defect
Yes
No
Congestive heart failure
Yes
No
Diabetes (type I or II)
Yes
No
Eating Disorder
Yes
No
Epilepsy
Yes
No
Emphysema
Yes
No
Fainting spells or seizures
Yes
No
Gastrointestinal disease
Yes
No
GERD / acid reflux / heartburn
Yes
No
Glaucoma
Yes
No
Heart Attack
Yes
No
Heart Murmur
Yes
No
Hemophilia
Yes
No
Hepatitis, jaundice, or liver disease
Yes
No
High Blood Pressure
Yes
No
Joint replacement (hip, knee, etc.)
Yes
No
Kidney problems
Yes
No
Low Blood Pressure
Yes
No
Malnutrition
Yes
No
Mental heath disorders
Yes
No
Mitral valve prolapse
Yes
No
Neurological disorders
Yes
No
Osteoporosis
Yes
No
Pacemaker
Yes
No
Persistent swollen glands in neck
Yes
No
Rheumatic fever / disease
Yes
No
Rheumatoid arthritis
Yes
No
Recurrent infections
Yes
No
Systemic lupus erythematous
Yes
No
Sinus trouble
Yes
No
Stroke
Yes
No
Sleep disorder / Sleep Apnea /CPAP
Yes
No
Severe headaches / migraines
Yes
No
Severe or rapid weight loss
Yes
No
Sexually Transmitted Disease
Yes
No
Thyroid Problems
Yes
No
Tuberculosis
Yes
No
Ulcers
Yes
No
Do you snore?
Yes
No
Do you use controlled substances (drugs)?
Yes
No
Do you use tobacco (smoking, snuff, chew, etc.)?
Yes
No
Do you drink alcoholic beverages?
Yes
No
Has it been recommended that you premedicate with antibiotics prior to dental treatment because of a medical condition?
Yes
No
Do you have any disease/condition/problem not listed above that you think we should know about?
Yes
No
I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE AND THAT THE INFORMATION GIVEN ON THIS FORM IS ACCURATE. I UNDERSTAND THE IMPORTANCE OF A TRUTHFUL HEALTH HISTORY AND THAT MY DENTIST AND HIS STAFF WILL RELY ON THIS INFORMATION FOR TREATING ME. I ACKNOWLEDGE THAT MY QUESTIONS, IF ANY, ABOUT INQUIRIES SET FORTH ABOVE HAVE BEEN ANSWERED TO MY SATISFACTION. I WILL NOT HOLD MY DENTIST, OR ANY OTHER MEMBER OF HIS STAFF, RESPONSIBLE FOR ANY ACTION THEY TAKE OR DO NOT TAKE BECAUSE OF ERRORS OR OMISSIONS THAT I MAY HAVE MADE IN THE COMPLETION OF THIS FORM *
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

HIPAA Acknowledgement

I understand that I may inspect or request a copy of the protected health information described by this authorization.

I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.

I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.

PLEASE COMPLETE:

I do NOT give permission to anyone. *
I give permission for the following individuals (husband/wife, friend, etc.) to access my personal information: *
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )
Thank you for visiting MK Periodontics & Implants. We want your visit to be pleasant and comfortable. Please help us by completing this form
Patient Information

Personal Details

Patient Name:
Preferred Name:
Date Of Birth:
SS#:
Marital Status:
Address:
City:
State:
Zip:
Cell#:
Home#:
Work#:
Email:
Occupation:
Employer:
Employer Address:
Is the Patient Under 18( Minor )?
   Yes    No
Responsible Party (If Minor):
Relationship:
Address (If Other Than Patient) :

Emergency Contact Information

Emergency Contact:
Relation:
Phone#:

Primary Insurance Information

Primary Insurance Company:
Phone#:
Member/Subscriber ID#:
Group#:
Policy Holder (If Other Than Patient):
Relationship:
SS#:
Date of Birth:
Phone#:
Do You have Primary Insurance?    Yes    No

Secondary Insurance Information

Secondary Insurance Company:
Phone#:
Member/Subscriber ID#:
Group#:
Policy Holder (If Other Than Patient):
Relationship:
SS#:
Date of Birth:
Phone#:
Do You have Secondary Insurance?    Yes    No
Additional Information
Who can we thank for referring you to our practice?:
General Dentist:
Phone#:
Pharmacy:
Phone#:
Location:
Medical History
Are you a woman?
    Yes    No
Are you currently under the care of a physician?
    Yes    No
Physician's Name:
Physician's Phone:
Have you had a serious illness/operation/hospitalization in the past 5 years?
    Yes    No
If yes, type details here:
Are you currently taking any prescription or OTC medicine(s)? If so, please list all:
    Yes    No
Are you allergic to any of the following?
   Local anesthetics    Aspirin/NSAIDS    Food    Metals
   Latex    Sulfa drugs    Iodine    Animals
   Penicillin / other antibiotics    Codeine / other narcotics    Barbiturates / other sedatives    Others
If Others, Please Specify:
Have you ever had any of the following diseases or problems?
   Abnormal Bleeding    AIDS or HIV infection    Anemia
   Angina    Artificial / damaged heart valves    Arthritis
   Asthma    Autoimmune disease    Bisphosphonate (Fosamax, Actonel, Boniva, Prolia, Reclast) for osteoporosis / Paget's disease
   Blood Transfusion    Cancer / chemotherapy / radiation    Cardiovascular disease
   Chest Pain    Chronic Pain    Congenital Heart Defect
   Congestive heart failure    Diabetes (type I or II)    Eating Disorder
Last A1C and Date:
   Emphysema    Epilepsy    Fainting spells or seizures
   Gastrointestinal disease    GERD / acid reflux / heartburn    Glaucoma
   Heart Attack    Heart Murmur    Hemophilia
   Hepatitis, jaundice, or liver disease    High Blood Pressure    Joint replacement (hip, knee, etc.)
   Kidney Problems    Low Blood Pressure    Malnutrition
   Mental heath disorders    Mitral valve prolapse    Neurological disorders
   Osteoporosis    Pacemaker    Persistent swollen glands in neck
   Rheumatic fever / disease    Rheumatoid arthritis    Recurrent infections
   Systemic lupus erythematous    Sinus trouble    Stroke
   Sleep disorder / Sleep Apnea /CPAP    Severe headaches / migraines    Severe or rapid weight loss
   Sexually Transmitted Disease    Thyroid Problems    Tuberculosis
   Ulcers
   Do you snore?
   Do you use controlled substances (drugs)?
   Do you use tobacco (smoking, snuff, chew, etc.)?
   Do you drink alcoholic beverages?
   Has it been recommended that you premedicate with antibiotics prior to dental treatment because of a medical condition?
   Do you have any disease/condition/problem not listed above that you think we should know about?
   I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE AND THAT THE INFORMATION GIVEN ON THIS FORM IS ACCURATE. I UNDERSTAND THE IMPORTANCE OF A TRUTHFUL HEALTH HISTORY AND THAT MY DENTIST AND HIS STAFF WILL RELY ON THIS INFORMATION FOR TREATING ME. I ACKNOWLEDGE THAT MY QUESTIONS, IF ANY, ABOUT INQUIRIES SET FORTH ABOVE HAVE BEEN ANSWERED TO MY SATISFACTION. I WILL NOT HOLD MY DENTIST, OR ANY OTHER MEMBER OF HIS STAFF, RESPONSIBLE FOR ANY ACTION THEY TAKE OR DO NOT TAKE BECAUSE OF ERRORS OR OMISSIONS THAT I MAY HAVE MADE IN THE COMPLETION OF THIS FORM
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

HIPAA Acknowledgement

I understand that I may inspect or request a copy of the protected health information described by this authorization.

I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.

I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.

PLEASE COMPLETE:

   I do NOT give permission to anyone.
   I give permission for the following individuals (husband/wife, friend, etc.) to access my personal information:
 
  
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

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