*Last Name: *First Name:
*Middle Initial: Suffix:
*City: *State: *Zip Code:
*What is the best way to contact you?
*Enter Phone Number:
*Work Phone: Work Fax:
Your Work Secretary's Name:
How did you hear about us?
Please select one
If other, please list:
*Date of last visit: (mm/dd/yyyy)
*Physician's phone #:
Do you have other physicians we need to know about?
If yes, please list:
*Do you, or have you had, any of the following? Check each appropriate box.
ALLERGIES TO DRUGS?
IF YES, TO WHAT?
ALLERGIES TO DENTAL ANESTHETICS:
DO YOU SMOKE
IF YES, HOW MUCH?
If yes, what month?
MITRAL VALVE PROLAPSE
HIGH/LOW BLOOD PRESSURE
ANEMIA/BLEEDING FROM CUTS or EXTS
BISPHOSPHONATES (STRENGTHEN BONES)
COUMADIN OR BLOOD THINNERS
LIVER DISEASE OR HEPATITIS
ORTHOPEDIC PROSTHESIS (HIPS, KNEES,ETC.)
DO YOU TAKE BIRTH CONTROL PILLS
HORMONE REPLACMENT THERAPY
Where (the portal)?
Does your physician require you to pre-medicate with antibiotics for dental treatment?
If yes, which antibiotic?
Please select one
If other antibiotic, please list:
*Describe any medical treatment you are presently undergoing (if none, enter "None"):
*List all medications you are presently taking, including their dosages (if none, enter "None"):
*Typing your full name in the textbox is your confirmation that the above information is accurate:
Please answer all questions including the consent for use and disclosure of health information
*Please Explain Your Chief Oral Complaint
Have you had a bleeding emergency from any dental treatment?
If yes, please explain:
Date of last dental treatment/exam: (mm/dd/yyyy)
Is this visit for a second opinion?
Although we do not accept insurance assignment, our statements may be submitted for reimbursement.
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
Please read the following statements carefully before signing this form
Purpose of consent: By signing this form, you consent to our use and disclosure of your protected health
information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide
whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and
healthcare operations, of the uses and disclosures we may make of your protected health information, and of
other important matters about your protected health information. A copy of our Notice accompanies this
Consent. We encourage you to read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we
change our privacy practices, we will issue a revised Notice of Privacy, which will contain the changes.
Those changes may apply to any of your protected health information that we maintain.
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of
your revocation submitted to: Executive Administrator, Central Park Periodontics, P.C., 40 Central Park South, Ste 2E, NY, NY 10019. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.
*Typing your full name in the textbox is your confirmation that the above information is accurate
I, ,have received and had full opportunity to read and
consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health
information to carry out treatment, payment activities, and healthcare.
*I give my consent on this date: (mm/dd/yyyy)
If this Consent is signed by a personal representative on behalf of the patient, please complete the following:
Personal Representative's Name:
Relationship to Patient: