PATIENT REGISTRATION

Patient Information

Additional Comments:

Primary Insurance Information

Responsible Party (if someone other than the patient)

ID:

First Name:

Policy Holder

Responsible Party

Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder

Section 2

Full Time Part Time Retired

Section 3

Address 2:

State / Zip:

Sex: Marital Status: Married Single Divorced Separated Widowed

E-mail: I would like to receive correspondences via e-mail.

Address:

City:

MaleOther

Female

Birth Date:

Full Time Part Time

Employment Status:

Student Status:

Medicaid ID: Pref. Dentist:

Employer ID: Pref. Pharmacy:

Carrier ID: Pref. Hyg.:

Name of Insured: Self Spouse Child Other

First Name:

Address 2:

First Name:

Address:

Home Phone:

Birth Date: Drivers Lic:Soc Sec:

Work Phone: Ext: Cellular:

City, State, Zip: Pager:

Last Name: Middle Initial:Last Name:

Insured Soc. Sec: Insured Birth Date:

Secondary Insurance Information

Name of Insured: Self Spouse Child Other

Rem. Deduct: .00

Employer:

Address:

Address 2:

City,State,Zip:

Ins. Company:

Address:

Address 2:

City,State,Zip:

Rem. Benefits: .00

Insured Soc. Sec: Insured Birth Date:

Employer:

Address:

Address 2:

City,State,Zip:

Ins. Company:

Address:

Address 2:

City,State,Zip:

Rem. Benefits: .00 Rem. Deduct: .00

Soc. Sec:Age: Drivers Lic:

Chart ID:

Home Phone: Work Phone:

Pager:

Ext: Cellular:

Last Name: Middle Initial:

Patient Is:

Relationship to Insured:

Relationship to Insured:

Preferred Name:

Printed copies of this document are considered uncontrolled. 15329.2.Rev001 10.07.2014

3801 N. Fairfax Dr, Suite 54Arlington, VA 22203(703)525-0157

MEDICAL HISTORY

PATIENT NAME _______________________________________________ Birth Date _____________________________________

Do you have, or have you had, any of the following?

Yes No

Are you allergic to any of the following?

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be

dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN __________________________________________________ DATE ______________________

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

following questions.

have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the

If yes, please explain:Are you under a physician's care now? Yes No

Have you ever had a serious head or neck injury?

Are you taking any medications, pills, or drugs?

Do you take, or have you taken, Phen-Fen or Redux?

Yes No If yes, please explain:

Yes No If yes, please explain:

Yes No If yes, please explain:

Comments:

Cortisone Medicine

Diabetes

Drug Addiction

Easily Winded

Emphysema

Epilepsy or Seizures

Excessive Bleeding

Excessive Thirst

Fainting Spells/Dizziness

Frequent Cough

Frequent Diarrhea

Frequent Headaches

Genital Herpes

Glaucoma

Hay Fever

Heart Attack/Failure

Heart Murmur

Heart Pacemaker

Heart Trouble/Disease

AIDS/HIV Positive

Alzheimer's Disease

Anaphylaxis

Arthritis/Gout

Artificial Heart Valve

Artificial Joint

Asthma

Blood Disease

Blood Transfusion

Breathing Problem

Bruise Easily

Cancer

Chemotherapy

Chest Pains

Cold Sores/Fever Blisters

Congenital Heart Disorder

Convulsions

HerpesAnemia

Angina

If yes, please explain:Yes NoHave you ever had any serious illness not listed above?

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Spina Bifida

Stomach/Intestinal Disease

Stroke

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Rheumatic Fever

Renal Dialysis

Radiation Treatments

Recent Weight Loss

Yes No

Yes No

Yes No

Hepatitis B or C

High Blood Pressure

Yes No

Yes No

Yes No

Yes No

Hemophilia

Hepatitis A

Pain in Jaw Joints

Parathyroid Disease

Psychiatric Care

Yes No

Yes No

Yes No

Hives or Rash

Hypoglycemia

Irregular Heartbeat

Kidney Problems

Leukemia

Liver Disease

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Swelling of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growths

Ulcers

Venereal Disease

Yellow Jaundice

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Yes No

Other

Aspirin

If yes, please explain:

Pregnant/Trying to get pregnant? Yes No Taking oral contraceptives? Yes No Nursing? Yes No

Women: Are you

Are you on a special diet? Yes No

Do you use tobacco? Yes No

Do you use controlled substances? Yes No

Yes No

Have you ever been hospitalized or had a major operation?

Have you ever taken Fosamax, Boniva, Actonel or anyother medications containing bisphosphonates? Yes No

Yes No

Metal Latex Sulfa drugsPenicillin Codeine Local Anesthetics Acrylic

High Cholesterol

Osteoporosis Yes No

Printed copies of this document are considered uncontrolled. 15329.1.Rev001 10.07.2014

3801 N. Fairfax Dr, Suite 54Arlington, VA 22203(703)525-0157

Group#

Relationship to Patient:

Member ID #

DENTAL INSURANCE INFORMATION

Insurance Company Name:Address:Phone Number:Insured’s Name:

Insured’s DOB:

Insured’sEmployer:

Employer Address:

FamilyMembers Covered Under my Plan:

Group#

Relationship to Patient:

Member ID #

SECONDARY DENTAL INSURANCE INFORMATION

Insurance Company NameAddress:Phone Number:Insured’s Name: Insured’s DOB:

Insured’sEmployer:EmployerAddress:Family Members Covered Under my Plan:

SIGNATURE ON FILE FOR RELEASE AND ASSIGNMENT I hereby authorize Layth Ghanim, DDS to release to the above listed insurance company, and its representatives, and information including the diagnosis and the records of any dental treatments or examinations rendered to me or to any other member of my family on my plan.

I also authorize and request the above named insurance company to pay directly to Layth Ghanim, DDS the amount due under my plan for dental treatments and services rendered to me or to family members.

I understand that signing on the signature line allows Dr. Ghanim’s office to put signature on file on the insurance forms so that I do not have to sign the forms each time I come to the office.

To avoid misunderstanding regarding dental insurance, we wish our patients to know that all professional services rendered are charged directly to the patient and the patient is personally responsible for payment of fees. We will prepare the necessary forms to help the patient obtain the maximum benefits available under his/her policy. We do not render our services on the basis that insurance companies will pay our fees or that the services rendered are covered under the patient’s insurance plan.

I understand that I am responsible for payment for fees for dental treatment and services rendered to me or to my family regardless of what my insurance may cover.

SIGNATURE: DATE

3801 N. Fairfax Dr, Suite 54Arlington, VA 22203(703)525-0157

Consent for Treatment, Insurance Assignment, Financial Responsibility

I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and my other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of my or my dependent’s dental needs.

Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required in providing proper care. I agree to the use of anesthetics, sedatives and other medications as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

I authorize release of any information concerning my own or my dependent’s health care for the purpose of evaluating and administering claims for health care benefits. I hereby authorize payment of insurance benefits directly to the doctor. I agree to be responsible for payment of all services rendered on my or my dependent’s behalf. I understand that payment is due at the time of service, unless other arrangements have been madea in advance of any services.

I have read the above policies of Arlington Dental Excellence and understand my responsibilities as a patient.

SIGNATURE OF RESPONSIBLE PARTY:

RELATIONSHIP TO PATIENT:

DATE:

3801 N. Fairfax Dr, Suite 54Arlington, VA 22203(703)525-0157

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.

Obtain payment from third-party payers.

Conduct normal healthcare operations such as quality assessments and physician certifications.

I have received, read and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Private Practices .

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

PATIENT NAME:

RELATIONSHIP TO PATIENT:

SIGNATURE:

DATE:

____________________________________________________________________________________

OFFICE USE ONLY

I attempted to obtain the patient’s signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below:

3801 N. Fairfax Dr, Suite 54Arlington, VA 22203(703)525-0157

I, , have received the Payment Options and Information. I understand that it is my responsibility to read, understand, and ask any questions that I may have regarding the Payment Options and Information. I will abide by my financial obligations to Arlington Dental Excellence.

PATIENT SIGNATURE:

DATE:

FRONT OFFICE ADMINISTRATOR:

DATE:

3801 N. Fairfax Dr, Suite 54Arlington, VA 22203(703)525-0157

Payment Options

Click Here to RESET

Final New patient form (Fillable form)New patient formsfinalpatient form Binder1Patient_Registration_Form_16_finalMedical_History_Form_16_final

insurance form

Consent for TreatmentNOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENTPayment Options

First Name: Last Name: Mid Initial: Policy Holder: OffResponsible Party: OffFIRST-NAME: LAST-NAME: MIDDLE INITIAL: Address 2: City State Zip: Home Phone: Work Phone: Ext: Cellular: Birth Date: Drivers Lic: Patient Information: OffAdderess: Adderess Optional: City: Zip Code: Home Phone_2: Work Phone_2: Text1: Cellular_2: Sex: OffMarital Status: OffBirth Date_2: Age: Driver LIC NUMBER: Email: I would like to receive correspondences via email: OffEmployment Status: OffStudent Status: OffMED ID: PREF DENTIST: Employer ID: PREF PHARMACY: Carrier ID: Name of Insured: Relationship to Insured: OffInsured Birth Date: Employer: Address_2: Address 2_2: CityStateZip: Ins Company: Address_3: Address 2_3: CityStateZip_2: Name of Insured_2: Relationship to Insured_2: OffInsured Birth Date_2: Employer_2: Address_4: Address 2_4: CityStateZip_3: Ins Company_2: Address_5: Address 2_5: CityStateZip_4: Birth Date_3: Check Box6: OffCheck Box7: OffCheck Box8: OffCheck Box9: OffCheck Box10: OffCheck Box11: OffCheck Box12: OffCheck Box13: OffCheck Box14: OffCheck Box1: OffCheck Box2: OffCheck Box3: OffCheck Box4: OffCheck Box5: OffCheck Box15: OffCheck Box16: OffCheck Box17: OffIf yes please explain: If yes please explain_2: If yes please explain_3: If yes please explain 1: If yes please explain 2: If yes please explain 3: Check Box18: OffCheck Box19: OffCheck Box20: OffCheck Box21: OffCheck Box22: OffCheck Box23: OffCheck Box24: OffAspirin: OffPenicillin: OffCodeine: OffLocal Anesthetics: OffAcrylic: OffMetal: OffLatex: OffSulfa drugs: OffOther_3: OffIf yes please explain_4: Check Box25: OffCheck Box26: OffCheck Box27: OffCheck Box28: OffCheck Box29: OffCheck Box30: OffCheck Box31: OffCheck Box32: OffCheck Box33: OffCheck Box34: OffCheck Box35: OffCheck Box36: OffCheck Box37: OffCheck Box38: OffCheck Box39: OffCheck Box40: OffCheck Box41: OffCheck Box42: OffCheck Box43: OffCheck Box110: OffCheck Box111: OffCheck Box112: OffCheck Box82: OffCheck Box83: OffCheck Box84: OffCheck Box85: OffCheck Box86: OffCheck Box87: OffCheck Box88: OffCheck Box89: OffCheck Box90: OffCheck Box92: OffCheck Box93: OffCheck Box94: OffCheck Box95: OffCheck Box96: OffCheck Box97: OffCheck Box44: OffCheck Box45: OffCheck Box46: OffCheck Box47: OffCheck Box48: OffCheck Box49: OffCheck Box50: OffCheck Box51: OffCheck Box52: OffCheck Box53: OffCheck Box54: OffCheck Box55: OffCheck Box56: OffCheck Box57: OffCheck Box58: OffCheck Box59: OffCheck Box60: OffCheck Box61: OffCheck Box62: OffCheck Box91: OffCheck Box63: OffCheck Box64: OffCheck Box65: OffCheck Box66: OffCheck Box67: OffCheck Box68: OffCheck Box69: OffCheck Box70: OffCheck Box71: OffCheck Box72: OffCheck Box73: OffCheck Box74: OffCheck Box75: OffCheck Box76: OffCheck Box77: OffCheck Box78: OffCheck Box79: OffCheck Box80: OffCheck Box81: OffCheck Box101: OffCheck Box99: OffCheck Box100: OffCheck Box102: OffCheck Box103: OffCheck Box104: OffCheck Box105: OffCheck Box106: OffCheck Box107: OffCheck Box108: OffCheck Box109: OffCheck Box113: OffCheck Box114: OffCheck Box115: OffCheck Box116: OffCheck Box117: OffCheck Box118: OffCheck Box119: OffCheck Box120: OffCheck Box121: OffCheck Box122: OffCheck Box123: OffCheck Box124: OffCheck Box125: OffCheck Box126: OffCheck Box127: OffCheck Box128: OffCheck Box129: OffCheck Box130: OffCheck Box131: OffCheck Box132: OffCheck Box133: OffCheck Box134: OffCheck Box135: OffCheck Box136: OffCheck Box137: OffCheck Box138: OffCheck Box139: OffCheck Box140: OffCheck Box141: OffCheck Box142: OffCheck Box143: OffCheck Box144: OffCheck Box145: OffCheck Box146: OffCheck Box147: OffCheck Box148: OffCheck Box149: OffCheck Box150: OffCheck Box151: OffCheck Box152: OffCheck Box153: OffCheck Box154: OffCheck Box155: OffCheck Box156: OffCheck Box157: OffCheck Box158: OffCheck Box159: OffCheck Box160: OffCheck Box161: OffCheck Box162: OffCheck Box163: OffCheck Box164: OffCheck Box165: OffCheck Box166: OffCheck Box167: OffCheck Box168: OffCheck Box169: OffCheck Box170: OffCheck Box171: OffCheck Box172: OffCheck Box173: OffCheck Box174: OffCheck Box175: OffCheck Box176: OffCheck Box177: OffCheck Box178: OffHave you ever had any serious illness not listed above: OffCheck Box98: OffComments 1: Comments 2: Comments 3: Comments 4: Comments 5: dangerous to my or patients health It is my responsibility to inform the dental office of any changes in medical status: Insureds Employer: Family Members Covered Under my Plan: Insurance company name: Phone #: Group#: Address: Member ID: Insurd Employer: Employer Address: Other family members on the plan: Insurd name: Phone Number: Insurd Name:: Insurd DOB: Date: Group #: Relationship to patient: Member ID#: DATE: PATIENT NAME: RELATIONSHIP TO PATIENT: NAME: DATE_2: RESET: