Policy Holder Responsible Party
Social Security #
Responsible Party is also a Policy holder for PatientPrimary Insurance Policy HolderSecondary Insurance Policy Holder
Social Security #
I would Like to receive correspondence via e-mailI don't wish to receive correspondence via e-mail
Full Time Part Time Retired
Full Time Part Time
Credit Card on File:
Care Credit Info:
Credit Card Exp Date:
Credit Card CVV:
Pref. Pharmacy Name:
Name of Insured:
Relation to Insured:
Self Spouse Child Other
Social Security #
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 can affect your dental health.
Are you under a physician care now?Yes No
Have you ever been hospitalized or had a major operation? Yes No
have you ever had a serious head or neck injury? Yes No
Are you taking any medications, pills, or drugs? Yes No
Do you take, or have taken, phen-Fen or Redux? Yes No
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Yes No
Are you on a special diet? Yes No
Do you use tobacco? Yes No
Do you use controlled substances? Yes No
Women: Are you..
Pregnant/Trying to be pregnant Nursing Taking oral contraceptives
Are you allergic to any of the followingAspirinPenicillinCodeineAcrylicMetalLatexSulfa DrugsLocal Anesthetics
Other? If yes
Do you have, or have you had, any of the following?
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.
The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you
have reviewed our notice before signing this consent.
The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.
You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare
operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health
Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or
By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous
usage in a public
Photographs, Videotapes, digital, or other images may be recorded to document my care and I consent to this. I understand that Rainforest Dental, PLLC will retain the ownership rights to these digital documents, and that I will be allowed access to view them or obtain copies. I understand that these documentations may be stored in a secured manner that will protect my privacy and that the digital documents that identify me will be released and/or used outside the facility only upon written authorization from me or my legal representative. (Initial)
I understand that I have the right to revoke this authorization in writing at any time. I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether I sign this authorization. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law
the following listed person(s) have my consent and authorization for Rainforest Dental, PLLC to use and/or disclose my personal protected health information:
This authorization is valid for all past and future time periods, unless requested differently by you, the patient. Id you would prefer a designated date range, Please state so here:
I authorize the release of my complete health record (Including records relating to communicable HIV or AIDS, treatment of alcohol or drug abuse, mental Healthcare).
I authorize the release of my complete health records with the exception of the following:
I do not wish to authorize the release of my records to anyone other than myself.
Name of patient, Personal representative or legal guardian and relationship to Patient:
This form provides authorization for the use or disclosure of your protected health information as required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164.