PATIENT REGISTRATION

First Name:

Patient Is:

Policy Holder

Responsible Party

Last Name: Middle Initial:

Preferred Name:

Responsible Party ( if someone other than the patient )

First Name: Last Name: Middle Initial:

Address: Address 2:

City, State, Zip: Pager:

Home Phone: Work Phone: Ext: Cellular:

Birth Date: Soc Sec: Drivers Lic:

Responsible Party is also a Policy Holder for Patient

Primary Insurance Policy Holder

Secondary Insurance Policy Holder

Patient Information

Address: Address 2:

City: State / Zip: Pager:

Home Phone: Work Phone: Ext: Cellular:

Sex:

Male

Female Marital Status:

Married

Single

Divorced

Separated

Widowed

Birth Date: Age: Soc Sec: Drivers Lic:

E-mail:

I would like to receive correspondences via e-mail.

Section 2

Section 3

Employment Status:

Full Time

Part Time

Retired

Student Status:

Full Time

Part Time

Pref. Dentist:

Employer ID: Pref. Pharmacy:

Carrier ID: Pref. Hyg:

Referred By

Previous Dentist

Emergency Contact

Primary Insurance Information

Name of Insured: Relationship to Insured:

Self

Spouse

Child

Other

Insured Soc. Sec: Insured Birth Date:

Employer:

Address:

Address 2:

City, State, Zip:

Rem. Benefits: Rem. Deduct:

Ins. Company:

Address:

Address 2:

City, State, Zip:

Insured Birth Date:

Employer:

Other

Insured Soc. Sec:

Address:

Rem. Benefits: Rem. Deduct:

Address 2:

City, State, Zip:

Secondary Insurance Information

Name of Insured:

Spouse

Child Relationship to Insured:

Self

Ins. Company:

Address:

Address 2:

City, State, Zip:

Emergency Contact #

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 bedangerous 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 MedicineDiabetesDrug AddictionEasily WindedEmphysemaEpilepsy or SeizuresExcessive BleedingExcessive ThirstFainting Spells/DizzinessFrequent CoughFrequent DiarrheaFrequent HeadachesGenital HerpesGlaucomaHay FeverHeart Attack/FailureHeart MurmurHeart PacemakerHeart Trouble/Disease

AIDS/HIV PositiveAlzheimer's DiseaseAnaphylaxis

Arthritis/GoutArtificial Heart ValveArtificial JointAsthmaBlood DiseaseBlood TransfusionBreathing ProblemBruise EasilyCancerChemotherapyChest PainsCold Sores/Fever BlistersCongenital Heart DisorderConvulsions

HerpesAnemiaAngina

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

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

RheumatismScarlet FeverShinglesSickle Cell DiseaseSinus TroubleSpina BifidaStomach/Intestinal DiseaseStroke

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Rheumatic FeverRenal Dialysis

Radiation TreatmentsRecent Weight Loss

Yes NoYes NoYes No

Hepatitis B or C

High Blood Pressure

Yes NoYes NoYes NoYes No

HemophiliaHepatitis A

Pain in Jaw JointsParathyroid DiseasePsychiatric Care

Yes NoYes NoYes No

Hives or RashHypoglycemiaIrregular HeartbeatKidney ProblemsLeukemiaLiver DiseaseLow Blood PressureLung DiseaseMitral Valve Prolapse

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Swelling of LimbsThyroid DiseaseTonsillitisTuberculosisTumors or GrowthsUlcersVenereal DiseaseYellow Jaundice

Yes NoYes NoYes NoYes NoYes NoYes NoYes NoYes No

Other

Aspirin

If yes, please explain:

Pregnant/Trying to get pregnant? Yes No Taking oral contraceptives? Yes No Nursing? Yes NoWomen: Are you

Are you on a special diet? Yes NoDo 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

DAVIS DENTAL CARE RYAN DAVIS,DMD

DAVIS DENTAL CARE

Ryan R. Davis, DMD 200 Corporate Pointe

Warner Robins, GA 31088 Phone 478.922.5882

Acknowledgement of Receipt of

HIPAA Notice of Privacy Practices

Last Updated: April 2015

ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES

Acknowledgement

I, ______________________________________, hereby acknowledge that I have received and reviewed a copy of DAVIS DENTAL CARE’s HIPAA Notice of Privacy Practices.

I understand that DAVIS DENTAL CARE’s HIPAA Notice of Privacy Practices may change periodically and that I am entitled to receive a copy of DAVIS DENTAL CARE’s revised HIPAA Notice of Privacy Practices upon request.

I understand that, if I have questions about DAVIS DENTAL CARE’s HIPAA Notice of Privacy Practices, I may contact

DAVIS DENTAL CARE Ryan R. Davis, DMD 200 Corporate Pointe, Warner Robins, GA 31088 Phone 478.922.5882 Fax 478.922.5910

I understand that it is my right to refuse to sign this Acknowledgement should I so choose, and that DAVIS DENTAL CARE will not refuse treatment to me if I refuse to sign this Acknowledgement.

I further understand that I may contact the Secretary of the U.S. Department of Health and Human Services should I have concerns regarding DAVIS DENTAL CARE’s privacy policies and procedures. For information on how to contact the U.S. Department of Health and Human Services, please ask Dr. Ryan Davis, noted above, for assistance.

Patient Signature Date

Signature of Personal Representative Print Name of Personal Representative

Relationship of Personal Representative to Patient

FOR OFFICE USE ONLY DAVIS DENTAL CARE made a good-faith effort to obtain Acknowledgement, from the patient noted above, of receipt of its HIPAA Notice of Privacy Practices. In spite of these efforts, DAVIS DENTAL CARE was unable to obtain a signed Acknowledgement for the following reason(s):

Refusal to sign Acknowledgement on _____________________________, 20______.

Communications barriers prohibited us from obtaining a signed Acknowledgement.

An emergency situation prohibited us from obtaining a signed Acknowledgement.

Other (Describe):_______________________________________________________

Date Received By Patient ID