NEW PATIENT REGISTRATION --

    Address
    Telephone

    INSURANCE INFORMATION --

    Relationship to Subscriber:
    SelfSpouseChildOther

    * Please present your insurance card to be photocopied for our records.

    RESPONSIBLE PARTY (if patient is a minor or different from patient listed above) --

    Address
    Telephone

    EMERGENCY CONTACT --

    AUTHORIZATION --

    I consent to the diagnostic procedures and dental treatment performed by my dentist, and to the release of information concerning my (or my child’s) health care, advice, and treatment to another dentist, or for evaluation and administering any claims for insurance benefits. I consent to the direct payment of my insurance benefits to the practice and understand my insurance may pay less than the actual bill for services and that I am responsible for any services not paid or covered.

    ELECTRONIC COMMUNICATIONS --

    I consent to receiving HIPAA-compliant electronic communications, such as email and text messages regarding treatment, payment, etc. I understand there is no obligation to receive these electronic communications.


    MEDICAL HISTORY --

    Patient

    Are you currently under the care of a physician?

    Have you ever had any serious illnesses or operations?
    YesNo

    Have you ever taken Bisphosphonates (IV or Oral)? If yes, please list type and dates taken

    Have you ever had head or neck radiation therapy?
    YesNo

    Are you taking any blood thinners? If yes, which one(s)

    List all medications you are taking:

    Are you allergic to:
    PenicillinClindamycinSulfa DrugsCodeineLatex
    Women Only
    Are you pregnant?
    YesNo
    Nursing?
    YesNo
    Taking Birth Control
    YesNo

    Please check if you have/had:

    Allergies, hay fever, sinusitis
    YesNo
    Emphysema
    YesNo
    Pacemaker
    YesNo
    Anemia
    YesNo
    Epilepsy
    YesNo
    Respiratory disease
    YesNo
    Arthritis, Rheumatism
    YesNo
    Fainting
    YesNo
    Rheumatic fever
    YesNo
    Artificial heart valve(s)
    YesNo
    Headaches
    YesNo
    Shortness of breath
    YesNo
    Artificial joint (s)
    YesNo
    Heart Murmur
    YesNo
    Sickle Cell Anemia
    YesNo
    Asthma
    YesNo
    Heart Problems
    YesNo
    Sinus trouble
    YesNo
    Bleeding abnormally with surgery
    YesNo
    Hepatitis type
    YesNo
    Stroke
    YesNo
    Blood disease, clotting disorders
    YesNo
    Herpes
    YesNo
    Slow healing wounds
    YesNo
    Cancer
    YesNo
    High blood pressure
    YesNo
    Swelling of ankles/feet
    YesNo
    Chemical dependency
    YesNo
    Immune deficiency
    YesNo
    Thyroid problems
    YesNo
    Chemotherapy
    YesNo
    Jaundice
    YesNo
    Tonsillitis
    YesNo
    Circulatory problems
    YesNo
    Kidney disease
    YesNo
    Tuberculosis
    YesNo
    Long term cortisone/steroid use
    YesNo
    Low blood pressure
    YesNo
    Tumor or growths
    YesNo
    Cough, persistent
    YesNo
    Mitral Valve prolapse
    YesNo
    Ulcers
    YesNo
    Diabetes
    YesNo
    Osteoporosis/osteopenia
    YesNo
    Venereal Disease
    YesNo

    DENTAL HISTORY:

    Have you had an allergic reaction to local or general anesthetics?
    YesNo
    Have you ever had trouble with/from prior dental treatment?
    YesNo

    APPOINTMENT CANCELLATION POLICY

    In our dental practice, we respect the importance of your time and we work very hard to schedule appointments that accommodate the scheduling needs of all our patients. We want you to know that we make every effort to see you at your scheduled appointment time. We greatly appreciate that you notify us at least 48 business hours prior to your scheduled appointment time, if you must CANCEL or RESCHEDULE your appointment. Please also note that a cancellation fee may be charged for an appointment if the appointment is cancelled or rescheduled without at least 48 hours notice.

    FINANCIAL POLICY

    All payments/co-payments for services are due at the time dental treatment is provided. Every effort will be made to provide a treatment plan for services with estimated costs, so that you can be prepared for payment on your next visit. As a courtesy to our patients, if you have dental insurance, we will file your dental insurance claims and bill your dental insurance company for treatment you receive. However, in the event the insurance company does not pay the estimated portion of the bill, the balance will become the patient’s responsibility and will be billed directly to you.

    PHOTOGRAPHY RELEASE/CONSENT

    I, hereby give Sunset Smile Creations, Dr. Victor D. Lubin and any of the employees the right and permission to use and/or publish photographs of me for clinical purpose only.
    Release of Claims: I, hereby release and discharge Sunset Smile Creations, Dr. Victor D. Lubin and all persons functioning under her permissions or authority from any legal or equitable claims.

    Check on the following:

    Yes, you may use my photos.No, please do not use my photos.

    Signature of Patient or Guardian:
    Date:

    ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES / USE AND DISCLOSURE FORM

    Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you. We provide this form to comply with the Health Insurance Portability and Accountability Act (HIPAA). Please review the Notice of Privacy Practices thoroughly before signing this acknowledgement form. If terms of our Notice change, a revised copy will be made available to you.

    By signing this form, you acknowledge that our practice may use and disclose PHI about you for treatment, payment and healthcare operations. You have the right to request that we restrict how PHI about you is used or disclosed for treatment, payment or healthcare operations.

    We cannot discuss your health information with anyone other than yourself unless you authorize us to do so. Please list below names of the individuals you authorize our office to discuss care with.

    I give you permission to share my health information with:

    Consent to email or text for appointment reminders and other healthcare communication.

    If you approve, we may contact you via email and/or text messaging to remind you of an appointment or provide general health reminders or information. I understand that once I have consented to receive communications via text or email, I still have the right to revoke the consent at any time.

    The cell phone number I authorize to receive text messages for appointment reminders and

    The cell phone number I authorize to receive email messages for appointment reminders and