PATIENT INFORMATION

We appreciate the confidence you have placed with us to provide Dental Care to you. All information on this chart is necessary for our records and is strictly confidential.




















REFFERAL INFORMATION

Please let us know how you heard about us


Yes


Yes


Yes



Yes



Yes



Yes

INSURANCE INFORMATION

Policy Holder Information













Policy Holder Information







DENTAL HISTORY PART 1



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DENTAL HISTORY PART 2

Do you:


Yes


Yes


Yes


Yes


Yes


Yes

If I could change my smile I would make my teeth


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


DENTAL HISTORY PART 3

Are any of your teeth sensitive to:


Yes


Yes


Yes

Are any of your teeth sensitive to:


Yes


Yes

Do your gums bleed or hurt? :


Yes


Yes


Do you:


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes

Have you ever had:


Yes


Yes


Yes


Yes


Yes


Yes


Have you experienced:


Yes


Yes


Yes


Yes


Yes


Yes


Yes



Yes



MEDICAL HISTORY PART 1

Please indicate which of the following you have had, or have at present:


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes



Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


MEDICAL HISTORY PART 2


Yes




No primary care doctor, please circle >>> NONE


Yes


Yes


Yes


Yes


Yes



Yes


Yes

MEDICAL HISTORY PART 3

Allergies


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes


Yes

Medications




MEDICAL HISTORY PART 4

Signature







PATIENT-DENTIST ARBITRATION AGREEMENT

Signature

Article I.
It is understood that any dispute as to dental malpractice, this, as to whether any dental services rendered under this
contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, would be determined by submission to arbitration as provided by California Law, and not by a lawsuit, or resort to court process,
except as California law provides for judicial review or arbitration proceedings. Both parties of this contract by entering
into it, have given up their constitutional right to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
Treatment in this office is contingent upon both parties consenting to this Arbitration Agreement.
Article II.
A. Parties to the Agreement:
The term “patient” as used in this agreement includes the undersigned individual, his or her spouse, children (whether
born or unborn), and heirs, assigns or personal representatives. The individual signing this Agreement signs it on behalf
of the foregoing persons, and intends to bind each of them to arbitration to the full extent permitted by law.
The term “doctor” as used in this agreement includes the undersigned doctor and his or her professional corporation
or partnership, and any employees, agents, successors in interest, heirs and assigns of the foregoing individuals or entities and independent contractors. The doctor signing this agreement signs it on behalf of all the foregoing individual
and entities, and intends to bind each of them to arbitration to full extent permitted by law.
B. Treatment Covered:
Patient understands and agrees that any dispute of the sort descried in Article I between doctor and patient will be
subject to compulsory, binding arbitration.
C. Coverage of Pre-Natal Claims (If Applicable):
Patient understands and agrees that, if doctor treats her during pregnancy, any dispute or sort descried in Article I as
to dental treatment rendered to or affecting the unborn child will be subject to compulsory, binding arbitration.
Article III.
A. Informal Resolution of Disputes:
In the event patient feels that a problem has arisen in connection with the dental care rendered by doctor to patient,
patient will promptly notify doctor so that doctor may have the opportunity to resolve the matter. Notice may be given
orally or in writing, and shall stop the running or statute of limitations forninety (90) days.
B. Method of Initiating Arbitration:
If the dispute is not resolved by mutual Agreement within ninety (90) days, patient may initiate arbitration by notifying
doctor to that affect. The arbitrator shall be selected by the chief administrator of JAMS ENDISPUTE. The arbitrator
must be selected within twenty-one (21) days of the signature on the receipt for a letter sent certified mail return receipt request demanding that a dispute submitted to arbitration. Following the selection of the arbitrator, arbitration
must be held within thirty (30) days.
C. Applicable Law:
The arbitration shall be conducted pursuant the California Arbitration Act (C.C.P. 1280-1296). The Arbitrator shall, in
addition, have authority to order such other discovery as he/she deemed appropriate for a full and fair hearing of the
case. A determination on the merits shall be rendered in accordance with the law of the State of California, including
the provisions of the Medical Injury Compensation Reform Act 1975 which shall apply to the same extent as if to dispute or pending before a Superior Court of the State of California.
The arbitrator shall not have the power to commit errors of law or legal reasoning, and the arbitrator’s decision may be
vacated or corrected pursuant the California Code of Civil Procedure Sections 12806.2 or 12086.6 for any such error.
The prevailing party shall be entitled to attorney fees.
Article IV.
A. Revocation:
If you are signing this agreement and then change your mind, the law permits you to revoke the Agreement providing
you give your doctor written notice within thirty (30) days of signing that you want to withdraw from the Agreement.
However, doctor and patient agree that any claim arising for dental services rendered prior to revocation shall be subjected to arbitration. Furthermore, doctor is not obligated to continue the doctor/patient relationship should you decide to withdraw from the agreement.
NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF DENTAL MALPRACTICE DECIDED
BY MUTUAL ARBITRATION AND YOU ARE GIVING UP RIGHT TO JURY OR COURT TRIAL, SEE ARTICLE I OF THIS CONTRACT.





HIPPA AGEEMENT PART 1

Protecting Your Confidential Health Information is Important to Us
Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can get access
to this information. Please review it carefully.

Our Promise!

Dear Patient:
This is not a meant to alarm you! Quite the opposite! It is our
desire to communicate to you that we are taking the new
Federal (HIPAA-Health Insurance Portability and Accountability
Act) laws written to protect the confidentiality of your health
information seriously. We do not ever want you to delay
treatment because you are afraid your personal health history
might be unnecessarily made available to others outside of our
office.

So what has changed? Why a privacy policy now? Very good
questions!

The most significant variable that has motivated the Federal
government to legally inforce the importance of the privacy of
health information is the rapid evolution of computer
technology and its use in healthcare. The government has
appropriately sought to standardize and protect the privacy of
the electronic exchange of your health information. This has
challenged us to review not only how your health information is
used within our computers but also with the internet, phone,
faxes, copy, machines, and charts. We believe this has been
important exercise for us because it has disciplined us to put in
writing the policies and procedures we use to ensure the
protection of your health information everywhere it is used.
We want you to know about these policies and procedures
which we developed to make sure your health information will
not be shared with anyone who does not require it. Our office is
subject to State and Federal law regarding the confidentiality of
our health information and in keeping with these laws, we want
you to understand our procedures and your rights as our
valuable patient.
We will use and communicate your HEALTH INFORMATION only
for the purposes of providing your treatment, obtaining
payment and conducing health care options. Your health
information will not be used for other purposes unless we have
asked for and been voluntarily given your written permission.

How your HEALTH INFORMATION may be used:

To Provide Treatment

We will use your HEALTH INFORMATION within our office to
provide you with the best dental care possible. This may include
administrative and clinical office procedures designed to
optimize scheduling and coordination of care between hygienist,
dental assistant, dentist, and business staff. In addition, we may
share your health information with physicians, referring dentist,
clinical and dental laboratories, pharmacies or other health care
personnel providing you treatment.

To Obtain Payment

We may include your health information with an invoice use to
collect payment for treatment you received in our office. We
may do this with insurance forms filed for you in the mail or sent
electronically. We will be sure to only work with companies with
similar commitment to the security of your health information.

To Conduct Health Care Operations

Your health information may be used during performance
evaluation of our staff. Some of our best teaching opportunities
use clinical situations experienced by patients receiving care at
our office. As a result, health information may be included in
training programs for students, interns, associates, and business
and clinical employees. It is also possible that health information
will be disclosed during audits by insurance companies or
government appointed agencies as part of their quality
assurance and compliance reviews. Your health information may
be reviewed during the routine processes of certification,
licensing or credentialing activities.

In Patient Reminders

Because we believe regular care is very important to your oral
and general health, we will remind you of a scheduled
appointment or that it is time for you to contact us and make an
appointment. Additionally, we may contact you to follow up on
your care and inform you of treatment options or services that
may be of interest to you or your family.
These communications are an important part of our philosophy
of partnering with our patients to be sure they receive the best
preventive and restorative care modern dentistry can provide.
They may include postcards, letters, telephone reminders, or
electronic reminders such as email (unless you tell us that you
do not want the receive these reminders.

Abuse or Neglect

We will notify government authorities if we believe a patient is
the victim of abuse, neglect, or domestic violence. We will make
this discloser only when we are compelled by our ethical
judgment, when we believe we are specifically required or
authorized by law or with the patient’s agreement.

HIPPA AGEEMENT PART 2

Protecting Your Confidential Health Information is Important to Us
Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can get access
to this information. Please review it carefully.

Public Health and National Security

We may be required to disclose to Federal officials or military
authorities health information necessary to complete an investigation related to public health or national security. Health information could be important when the government believes that
the public safety could benefit when the information could lead
to the control or prevention of an epidemic or the understanding of new side effects of a drug treatment or medical device.

For Law Enforcement

As permitted or required by State of Federal law, we may disclose your health information to a law enforcement official for
certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to
report crime.

Family, Friends and Caregivers

We may share your health information with those you tell us will
be helping you with home hygiene, treatment, medications, or
payment. We will be sure to ask your permission first, In the
case of an emergency, where you are unable to tell us what you
want we will use our very best judgement when sharing your
health information only when it will be important to those participating in providing your care.

Authorization to Us or Disclose Health Information

Other than what is stated above or where Federal, State or Local
law requires of us, we will not disclose your health information
other than with your written authorization. You may revoke that
authorization in writing at any time.

Patient Rights

This new law is careful to describe that you have the fallowing
rights to your health information.

Restrictions

You have the right to request restrictions on certain uses and
disclosures of your health information. Our office will make every effort to honor reasonable restriction preferences from our
patients.

Confidential Communications

You have the right to request that we communicate with you in
a certain way. You may request that we only communicate your
health information privately with no other family members present or through mail communications that are sealed. We will
make every effort to honor your reasonable requests for confidential communications.

Inspect and Copy Your Health Information

You have the right to read, review and copy your health information, including you complete chart, x-rays and billing records.
If you would like a copy of your health information, please let us
know. We may need to charge you a reasonable fee to duplicate
and assemble your copy.

Amend Your Health Information

You have the right to ask us to update or modify your records if
you believe your health information records are incorrect or
incomplete. We will be happy to accommodate you as long as
our office maintains this information. In order to standardize our
process, please provide us with your request in writing and describe your reason for the change.
Your request may be denied if the health information record in
question was not created by our office, is not part of our records
or if the records containing your health information are determined to be accurate and complete.

Documentation of Health Information

You have the right to ask us for a description of how and where
your health information was used by our office for any reason
other than treatment, payment or health operations. Our documentation procedures will enable us to provide information on
health information usage form April 14, 2003 and forward.
Please let us know in writing the time period for which you are
interested. Thank you for limiting your request to no more than
six years at a time. We may need to charge you a reasonable fee
for your request.

Request a Paper Copy of this Notice

You have the right to obtain a copy of this Notice of Privacy Practice directly from our office at any time. Stop by or give us a call
and we will mail or email a copy to you.
We are required by law to maintain the privacy of your health
information and to provide to you and your representative this
Notice of our Privacy Practices. We are required to practice the
policies and procedures described in this notice but we do reserve the right to change terms of our Notice. If we change our
privacy practices we will be sure all our patients receive a copy
of the revised Notice.
You have the right to express complaints to us or to the Secretary of Health and Human Services if you believed your privacy
rights have been compromised. We encourage you to express
any concerns you may have regarding the privacy of your information. Please let us know of your concerns or complaints in
writing.

Patient Acknowledgment

Patient Name(s)

Thank you very much for taking the time to review how we are
carefully using your health information. If you have any questions we want to hear from you. If not, we would appreciate very
much you acknowledging your receipt of our policy by signing
and returning this paper. We look forward to seeing you again
soon!