Welcome to our office! In an effort to provide the best service possible, we ask you to fill out this form as completely as possible and click the "Submit" button at the very end. Thank you for your cooperation and we look forward to seeing you soon!

Patient Information

Responsible Party Information

Emergency Information

Dental Insurance Information



Medical History


Please fill out the following fields and elaborate as necessary.

Dental History



How did you hear about us?

Referring new patients to our office is the highest compliment we can receive. Please take a moment to let us know all the ways you heard about our office. Put a check next to each source. Thank you!

Please list all of your friends that referred you here, so we may thank them properly.

Stephen S. Yang, DMD, MS, Inc


Notice of Privacy Practices

This notice describes how your health information may be used and disclosed and how you can access this information. Please review it carefully. Protecting our patients’ privacy has always been important to this practice. A new state and federal law, Health Insurance Portability and Accountability Act (HIPAA), goes into effect as of April 14, 2003 and requires us to inform you of our policy.

At Stephen S. Yang, DMD, MS, Inc., we have always kept your health information secure and confidential. This new law requires us to continue maintaining your privacy, to give you this notice and to follow the terms of this notice. The law permits us to use or disclose your health information to those involved in your treatment. For example, a review of your file by a specialist doctor whom we may involve in your care.
We may use or disclose your health information for payment of your services. For example, we may send a report of your progress to your insurance company.
We may use or disclose your health information for our normal healthcare operations. For example, one of our staff will enter your information into our computer.
We may share your medical information with our business associates, such as a billing service. We have a written contract with each business associate that requires them to protect your privacy.
We may use your information to contact you. For example, we may send newsletters or other information. We may also want to call and remind you about your appointments. If you are not home, we may leave this information on your answering machine or with the person who answers the telephone.
We may use your xrays, treatment photos, or any photos taken in the office for educational or marketing purposes. In an emergency, we may disclose your health information to a family member or another person responsible for your care.
We may release some or all of your health information when required by law.
If this practice is sold, your information will become the property of the new owner.
Except as described above, this practice will not use or disclose your health information without your prior written authorization.
You may request in writing that we not use or disclose your health information as described above. We will let you know if we can fulfill your request.
You have the right to know of any uses or disclosures we make with your health information beyond the above normal uses. Calls to and from the office may be monitored or recorded for quality training purposes.
As we will need to contact you from time to time, we will use whatever address or telephone number you prefer. You have the right to transfer copies of your health information to another practice. Give us a written request indicating the copies you want transferred and we will mail (or e-mail) your files for you. We may charge you a reasonable fee for this service.
You have the right to see or receive a copy of any of your health information, with a few exceptions. Give us a written request regarding the information you want to see or have copied. We may charge a reasonable fee for the copies.
You have the right to request an amendment or change to your health information. Give us your request to make changes in writing. If you wish to include a statement in your file, please give it to us in writing. We may or may not make the changes you request, but will be happy to include your statement in your file. If we agree to an amendment or change, we will not remove or alter earlier documents, but will add new information.
You have the right to receive a copy of this notice.
If we change any of the details of this notice, we will notify you of the changes in writing.
You may file a complaint with the Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509E, Washington, D.C. 20201. You will not be retaliated against for filing a complaint.
However, before filing a complaint, or for more information or assistance regarding your health information privacy, please contact our Privacy Office, Mirian Osorio at (650) 366-5758.

Acknowledgement

I have received a copy of the Stephen S. Yang, DMD, MS, Inc. Notice of Privacy Practices.

AAOIC SUPPLEMENTAL HEALTH QUESTIONNAIRE

If you have been exposed to a communicable disease, you may spread the disease to the orthodontist, orthodontic staff, or other patients/parents in the practice. Therefore, prior to each appointment, we may be asking the following questions to reduce the chances of transmission:



Do you currently have:


I understand that if the answer to any of these questions is yes, I may be asked to reschedule today’s orthodontic appointment.


SUPPLEMENTAL INFORMED CONSENT

Orthodontic Treatment in the Era of COVID-19


Thank you for your continued trust in our practice. As with the transmission of any communicable disease like a cold or the flu, you may be exposed to COVID-19, also known as “Coronavirus,” at any time or in any place. Be assured that we have always followed state and federal regulations and recommended universal personal protection and disinfection protocols to limit transmission of all diseases in our office and continue to do so.

Despite our careful attention to sterilization, disinfection, and use of personal barriers, there is still a chance that you could be exposed to an illness in our office, just as you might be at your gym, grocery store, or favorite restaurant. “Social Distancing” nationwide has reduced the transmission of the Coronavirus. Although we have taken measures to minimize exposure, due to the nature of the procedures we provide, it is not possible to maintain social distancing between the patient, orthodontist, orthodontic staff and sometimes other patients at all times.


By signing below, I accept the risk and consent to treatment.