Patient Registration

Name:



Patient Is:

Policy Holder Responsible Party

Responsible Parts (if someone other than the patient)

Name:



Address:



Phone:



Birth Date:

Social Security #

Drivers Lic:

Responsible Party is also a Policy holder for PatientPrimary Insurance Policy HolderSecondary Insurance Policy Holder

Patient Information

Address:



Phone:



Sex:
Male Female
Marital Status:
MarriedSingleDivorcedSeparatedWidowed

Birth Date:

Age:

Social Security #

Drivers Lic:

Email:
I would Like to receive correspondence via e-mailI don't wish to receive correspondence via e-mail

Section 2

Employment Status:
Full Time Part Time Retired
Student Status:
Full Time Part Time
Medicaid ID:
Employer ID:
Carrier ID:
Pref. Dentist:
Pref. Pharmacy:
Prf. Hyg:

Section 3

Credit Card on File:
Contact Info:
Care Credit Info:
Credit Card Exp Date:
Credit Card CVV:
Preferred Pharmacy#
Pref. Pharmacy Name:

Primary Insurance Information

Name of Insured:
Relation to Insured:
Self Spouse Child Other
Social Security #
Insured DOB:
Employer:
Address:



Rem. Benefits:
Rem. Deduc:
Insurance Company:
Address:


Secondary Insurance Information

Name of Insured:
Relation to Insured:
Self Spouse Child Other
Social Security #
Insured DOB:
Employer:
Address:



Rem. Benefits:
Rem. Deduc:
Insurance Company:
Address:


Medical History

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.

Patient Name:
Birth Date:
Today's Date:
Are you under a physician care now?
Yes No
If yes
Have you ever been hospitalized or had a major operation?
Yes No
If yes
have you ever had a serious head or neck injury?
Yes No
If yes
Are you taking any medications, pills, or drugs?
Yes No
If yes
Do you take, or have taken, phen-Fen or Redux?
Yes No
If yes
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Yes No
If yes
Are you on a special diet?
Yes No
If yes
Do you use tobacco?
Yes No
If yes
Do you use controlled substances?
Yes No
If yes

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?

AIDS/HIV Positive YesNo
Alzheimer's Disease YesNo
Anaphylaxis YesNo
Anemia YesNo
Angina YesNo
Arthritis/Gout YesNo 
Artificial Heart Valve YesNo
Artificial Joint YesNo
Asthma YesNo
Blood Disease YesNo
Blood Transfusion YesNo
Breathing Problems YesNo
Bruise Easily YesNo
Cancer YesNo
Chemotherapy YesNo
Chest Pains YesNo
Cold Sores/Fever Blisters YesNo
Congenital Heart Disorder YesNo
Convulsions YesNo
Cortisone Medication YesNo
Diabetes YesNo
Drug Addiction YesNo
Easily Winded YesNo
Emphysema YesNo
Epilepsy or Seizures YesNo
Excessive Bleeding YesNo
Excessive Thirst YesNo
Fainting Spells/Dizziness YesNo
Frequent Cough YesNo
Frequent Diarrhea YesNo
Frequent Headaches YesNo
Genital Herpes YesNo
Glaucoma YesNo
Hay Fever YesNo
Heart Attack/Failure YesNo
Heart Murmur YesNo
Heart Pacemaker YesNo
Heart Trouble/Disease YesNo
Hemophilia YesNo
Hepatitis A YesNo
Hepatitis B or C YesNo
Herpes YesNo
High Blood Pressure YesNo
High Cholesterol YesNo
Hives or Rash YesNo
Hypoglycemia YesNo
Irregular Heartbeat YesNo
Kidney Problems YesNo
Leukemia YesNo
Liver Disease YesNo
Low Blood Pressure YesNo
Lung Disease YesNo
Mitral Valve Prolapse YesNo
Osteoporosis YesNo
Pain in Haw Joint YesNo
Parathyroid Disease YesNo
Psychiatric Care YesNo
Radiation Treatments YesNo
Recent Weight Loss YesNo
Renal Dialysis YesNo
Rheumatic Fever YesNo
Rheumatism YesNo
Scarlet Fever YesNo
Shingles YesNo
Sickle Cell Disease YesNo
Sines Trouble YesNo
Spina Bifida YesNo
Stomach/Intestinal Disease YesNo
Stroke YesNo
Swelling of Limbs YesNo
Thyroid Disease YesNo
Tonsillitis YesNo
Tuberculosis YesNo
Tumors or Growths YesNo
Ulcers YesNo
Venereal Disease YesNo
Yellow Jaundice YesNo
Have you ever had any serious illness not listed above? YesNO
If yes:

HIPAA Compliance Patient Consent Form

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
healthcare operations.

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)

Authorization to Release Personal Health Records

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:

Named person(s):
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.