Patient Sign-in

Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history

Patient Registration( * mandatory to fill )

  Yes    No

Guardian Information

  Phone Call    Email    Text
  Family    Friend    Web Search    Social Media    Yelp    Self

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

Please select below

Is the Patient Responsible for the Bill?
Yes No
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
 
(Please click below to draw/upload sign)
(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 )

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

(All questions are required * )

Do you have a personal physician?
Yes
No
Your current physical health is
Good
Fair
Poor
Are you currently under the care of a physician?
Yes
No
Do you use tobacco in any form?
Yes
No
Have you had any metal rods, pins or implants placed?
Yes
No
Are you taking any medications?
Yes
No
Have you ever had any surgical procedures?
Yes
No
I have answered all the above questions

Medical History

Are you a woman?
Yes
No
Are you taking contraceptives or other hormones?
Yes
No
Are you pregnant?
Yes
No
Are you Nursing
Yes
No
Have you reached menopause?
Yes
No
Are you allergic to any of the following?
I have answered all the above questions

Medical History

Do you or have you experienced the following?

Abnormal Bleeding
Yes
No
Alcohol Abuse
Yes
No
Allergies
Yes
No
Anemia
Yes
No
Angina Pectoris
Yes
No
Arthritis
Yes
No
Artificial Heart Valves
Yes
No
Asthma
Yes
No
Artificial Bones/Joints
Yes
No
Blood Problems
Yes
No
Blood Transfusion
Yes
No
Breathing Problems
Yes
No
Bruise Easily
Yes
No
Cancer
Yes
No
Chemotherapy
Yes
No
Colitis
Yes
No
Chest Pain
Yes
No
Cold sores / Fever blisters
Yes
No
Congenital Heart Defect
Yes
No
Convulsion
Yes
No
Cortisone medicine
Yes
No
Diabetes
Yes
No
Difficulty Breathing
Yes
No
Drug Abuse
Yes
No
Easily Winded
Yes
No
Emphysema
Yes
No
Epilepsy
Yes
No
Facial Surgery
Yes
No
Excessive Thirst
Yes
No
Fainting spells
Yes
No
Fever Blisters
Yes
No
Frequent Diarrhea
Yes
No
Frequent Headaches
Yes
No
Genital Herpes
Yes
No
Glaucoma
Yes
No
HIV+ AIDS
Yes
No
Hay Fever
Yes
No
Heart Attack
Yes
No
Heart Murmur
Yes
No
Heart Surgery
Yes
No
Hemophilia
Yes
No
Hepatitis A
Yes
No
Hepatitis B or C
Yes
No
Herpes or other STD
Yes
No
High Blood Pressure
Yes
No
Joint Replacement
Yes
No
Hives or Rash
Yes
No
Hypoglycemia
Yes
No
Irregular Heartbeat
Yes
No
Kidney Problems
Yes
No
Leukemia
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Lung diseases
Yes
No
Mitral Value prolapse
Yes
No
Pace Maker
Yes
No
Osteoporosis
Yes
No
Pain in Jaw Joints
Yes
No
Parathyroid Disease
Yes
No
Psychiatric Problems
Yes
No
Radiation Therapy
Yes
No
Recent Weight Loss
Yes
No
Renal Dialysis
Yes
No
Rheumatic Fever
Yes
No
Seizures
Yes
No
Sexually Transmitted Disease
Yes
No
Shingles
Yes
No
Sickle Cell Disease
Yes
No
Sinus Problems
Yes
No
Spina Bifida
Yes
No
Stomach/Intestinal Disease
Yes
No
Stroke
Yes
No
Swelling of Limbs
Yes
No
Thyroid Problems
Yes
No
Tonsillitis
Yes
No
Tuberculosis
Yes
No
Tumors or Growths
Yes
No
Ulcers
Yes
No
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

HIPAA - Use & Disclosure of Protected Health Information

Patient Authorization & Acknowledgement of Receipt

Authorization for the disclosure of Protected Health Information(PHI) for treatment,Payment, or Healthcare Operations(164.508(a)).

I, the undersigned, understand that as part of my health care, Elena Shabani DDS, Inc. originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for furture care of treatment. I understand that this information servers as:

  • A basis for planning my care and treatment;
  • A means of communication among the health professionals who may contribute to my health care;
  • A source of information for applying my diagnosis and surgical information to my bill;
  • A means by which a third-party prayer can verify that services billed were actually provided;
  • A tool for routine healthcare operations such as assessing quality and reviewing the competence of health care professionals.

I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

Patient Consent for Use & Disclosure of PHI

Consent to the use and disclosure of Protected Health Information(PHI) for Teatment, Payment, or Healthcare Operations(TPO) (164.506(a))

I understand that:

  • I have the right to review the provider's Notice of Privacy Practices prior to signing this consent;
  • The provider reserves the right to revise its Notice of Privacy Practices at any time and that prior to implementation will mail a copy of any revised notice to the address I have provided, if requested;
  • I have the right to object to the use of my health information for directory purposes;
  • I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or health care operations and that the provider has already taken action in reliance thereon.

By signing below, I hereby give my consent to use and disclose my protected health information(PHI) to carry out treatment, payment and health care operations(TPO).

We may also use any of the following methods to send you appointent reminders, patient statements, surveys, occasional news, educational messages, and information related to insurance issues or your clinical care, including laboratory test results, etc:

  • Mail - to home or other alternate location.
  • Telephone - cell phone, home or alternate number. (We may also leave a message on your voicemail)
  • Text messages(standard text messaging rates may apply)
  • Emails

I understand that I can withdraw my consent at any time.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )
Thank you for visiting Shabani Dental. We want your visit to be pleasant and comfortable. Please help us by completing this form
Patient Information

Personal Details

Title:           First Name:           Last Name:           Date Of Birth:           Social Security Number:           Gender:           Marital Status:           Home Phone No:           Cell Phone No:           Address:           City:           State:           Zip Code:           Occupation:           Employer:           Employer Phone No.:           Email Address:          
Is the Patient Under 18( Miner )? Yes No

Guardian Details

First Name:           Last Name:           Date Of Birth:           Phone Number:           Relation to Patient:          
Phone Call Email Text
Family Friend Web Search Social Media Yelp Self

Emergency Contact Information

Name: Relation: Home Phone: Work Phone: Street Address: City: State: Zip Code:

Primary Insurance Information

Name of Primary Insurance: Subscriber's Name: Birth Date: Policy No: Group #: Patient's Relationship to Subscriber:
Do You have Primary Insurance? Yes No

Secondary Insurance Information

Name of Secondary Insurance: Subscriber's Name: Birth Date: Policy No: Group #: Patient's Relationship to Subscriber:
Do You have Secondary Insurance? Yes No

Responsible Person for the Bill

Person Responsible for Bill: Birth Date: Address(if different): Home Phone Number: Occupation: Employer: Employer Address: Employer Phone No:
Medical History
Do you have a personal physician?
Yes
No
Physician's Name: Physician's Phone: Date of Last Visit:
Your current physical health is
Good
Fair
Poor
Are you currently under the care of a physician?
Yes
No
Please explain:
Do you use tobacco in any form?
Yes
No
Have you had any metal rods, pins or implants placed?
Yes
No
Are you taking any medications?
Yes
No
Please list each one:
Have you ever had any surgical procedures ?
Yes
No
Please list each one:
Are you a woman?
Yes
No
Are you allergic to any of the following?
Aspirin Codeine Local anesthetics Acrylic
Jewellery Latex Metals Penicillin
Sulfa drugs Others
If Others, Please Specify:
Nearest relative not living with you:
Name Relationship Address Phone
Do you or Have you experienced the following ?
Abnormal Bleeding Alcohol Abuse Allergies
Anemia Angina Pectoris Arthritis
Artificial Heart Valves Artificial Bones/Joints Asthma
Blood Problems Blood Transfusion Breathing Problems
Bruise Easily Cancer Chemotherapy
Colitis Chest Pain Cold sores / Fever blisters
Congenital Heart Defect Convulsion Cortisone medicine
Diabetes Difficulty Breathing Drug Abuse
Easily Winded Emphysema Epilepsy
Facial Surgery Excessive Thirst Fainting spells
Fever Blisters Frequent Diarrhea Frequent Headaches
Genital Herpes Glaucoma HIV+ AIDS
Hay Fever Heart Attack Heart Murmur
Heart Surgery Hemophilia Hepatitis A
Hepatitis B or C Herpes or other STD High Blood Pressure
Joint Replacement Hives or Rash Hypoglycemia
Irregular Heartbeat Kidney Problems Leukemia
Liver Disease Low Blood Pressure Lung diseases
Mitral Value prolapse Pace Maker Osteoporosis
Pain in Jaw Joints Parathyroid Disease Psychiatric Problems
Radiation Therapy Recent Weight Loss Renal Dialysis
Rheumatic Fever Seizures Sexually Transmitted Disease
Shingles Sickle Cell Disease Sinus Problems
Spina Bifida Stomach/Intestinal Disease Stroke
Swelling of Limbs Thyroid Problems Tonsillitis
Tuberculosis Tumors or Growths Ulcers
 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

HIPAA - Use & Disclosure of Protected Health Information

Patient Authorization & Acknowledgement of Receipt

Authorization for the disclosure of Protected Health Information(PHI) for treatment,Payment, or Healthcare Operations(164.508(a)).

I, the undersigned, understand that as part of my health care, Elena Shabani DDS, Inc. originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment and any plans for furture care of treatment. I understand that this information servers as:

  • A basis for planning my care and treatment;
  • A means of communication among the health professionals who may contribute to my health care;
  • A source of information for applying my diagnosis and surgical information to my bill;
  • A means by which a third-party prayer can verify that services billed were actually provided;
  • A tool for routine healthcare operations such as assessing quality and reviewing the competence of health care professionals.

I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures.

Patient Consent for Use & Disclosure of PHI

Consent to the use and disclosure of Protected Health Information(PHI) for Teatment, Payment, or Healthcare Operations(TPO) (164.506(a))

I understand that:

  • I have the right to review the provider's Notice of Privacy Practices prior to signing this consent;
  • The provider reserves the right to revise its Notice of Privacy Practices at any time and that prior to implementation will mail a copy of any revised notice to the address I have provided, if requested;
  • I have the right to object to the use of my health information for directory purposes;
  • I have the right to request restrictions as to how my protected health information may be used or disclosed to carry out treatment, payment, or health care operations and that the provider has already taken action in reliance thereon.

By signing below, I hereby give my consent to use and disclose my protected health information(PHI) to carry out treatment, payment and health care operations(TPO).

We may also use any of the following methods to send you appointent reminders, patient statements, surveys, occasional news, educational messages, and information related to insurance issues or your clinical care, including laboratory test results, etc:

  • Mail - to home or other alternate location.
  • Telephone - cell phone, home or alternate number. (We may also leave a message on your voicemail)
  • Text messages(standard text messaging rates may apply)
  • Emails

I understand that I can withdraw my consent at any time.

 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
Name: Relationship:
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