ACQUAINTANCE FORM

Date:

Dr.Mr.Mrs.Ms.Miss.

Last:Last

First:First

Middle:Middle

Address:Street

City

State

Zip Code

Birthdate:

E-mail Address:

Employer/Occupation:

Phone #1:

CellHomeWork

Phone #2:

CellHomeWork

Pharmacy Name, City:

Pharmacy Phone #:

By whom were you referred?

DENTAL HISTORY:

What is your immediate dental concern?

General Dentist

Dental Specialists

MEDICAL HISTORY

Family Physician

Location

Additional Physicians

Please list medical conditions you are currently being treated for or take medications for:

Please list your medications, vitamins, and supplements below:

If this is an extensive list, please feel free to bring a copy to the office or upload your list here:

Attach a File

Please list any major operations you have had and the year you had it:

Have you been told to pre-medicate with antibiotics for dental care?

YesNo

If Yes, with:

Are you allergic to any medications?

YesNo

If yes, please list:

Do you take a daily aspirin?

YesNo

If yes, how much?

Do you use tobacco products?

YesNo

If yes, how much?

Have you ever taken bone modifying or immunosuppressive meds?

YesNo

If Yes:

Have you ever had a problem with any of the following:

Yes

No

Yes

No

Yes

No

Yes

No

YesNo Heart trouble/murmur

YesNo Rheumatic fever

YesNo High/low blood pressure

YesNo Chest pain/short of breath

YesNo Swollen ankles

YesNo Diabetes

YesNo Stroke

YesNo Anemia

YesNo Dizziness/Fainting

YesNo Headaches

YesNo Nervous Disorders

YesNo Asthma/Hay fever

YesNo Tuberculosis

YesNo Infectious Hepatitis

YesNo HIV

YesNo Cancer

YesNo Arthritis

YesNo Alcohol

YesNo Bulimia/Anorexia

YesNo Recreational Drugs

Patient’s Signature

Please use your mouse to sign this

FINANCIAL RESPONSIBILITY FORM

We welcome discussion of fees prior to care as payment will be due at the time of service. Our office is an out-of-network provider for Dental PPO, DMO, and Medical insurance programs. We accept cash, personal check, and all major credit cards. If you have Dental PPO Insurance, you will still receive your benefits if you provide all your current information. We are here to help you reach your periodontal goals. In return, we expect our patients to understand and acknowledge their financial responsibilities listed below:

Payment for all services rendered is your financial responsibility.
We are an "out-of-network" provider and charge by a fee schedule that is consistent with industry standards.
You can still benefit from a Dental PPO Insurance. Please provide your complete insurance information at the bottom of the page. We will submit our charges to your insurance carrier for payment. You are responsible for all charges if you do not provide complete and accurate insurance information.
In accordance with the No Surprises Act, treatment fee estimates will be provided. Please understand that financial estimates are only estimates and are not a contract. Treatment plans can change during procedures, and insurance payments can change during final processing. We will do our best to communicate before, during, and after a procedure regarding possible changes.
If you have a Dental PPO Insurance and would like to know what your insurance will cover prior to treatment, a pre-determination or estimate of benefits ("pre-d" or "EOB") will be submitted on your behalf. Each insurance plan has its own specific guidelines, and it is best to confirm with them through these submissions.Your insurance company will mail you their response in 2-6 weeks after your treatment plan has been determined and submitted. If you choose to receive treatment prior to receiving this estimate, our experienced staff will determine an estimate of fees which will be due on the date of service. After your insurance carrier processes your claim, a bill will be generated for any remaining balance. If your insurance claim notifies us that you have overpaid, a reimbursement will be issued as a check and mailed to the address you provide on your Acquaintance Form unless otherwise specified.
We apologize that we are unable to submit to Dental DMO, Medical PPO, and Mecial HMO Insurance Plan.

All patients are required to sign an acknowledgement of their financial responsibility. In the event you choose not to sign the acknowledgment of responsibility, Maki Ishii, DMD, P.C. reserves the right to withhold treatment. Please discuss any questions or concerns with our staff.

Signed:

Please use your mouse to sign this

Date:

PRIMARY DENTAL INSURANCE:

Name of Insured:

Your Relationship to Insured:

Employer of Insured:

Insured’s Address:

Insured’s Telephone:

Birthdate of Insured:

ID # of Insured:

Group Number:

SECONDARY DENTAL INSURANCE:

Name of Insured:

Your Relationship to Insured:

Employer of Insured:

Insured’s Address:

Insured’s Telephone:

Birthdate of Insured:

ID # of Insured:

Group Number:

HIPAA Notice of Privacy Practices

NOTIFICATION FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: PATIENT RECEIVING NOTIFICATION:

Full Name:

Date of Birth:

Home Address:

SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENT CAREFULLY.

Purpose of Notification: To inform you that your protected health information will be used and disclosed to carry out treatment, payment activities, health care operations, and collaboration with other dental providers for care and education.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Signature and Acknowledgment of Receipt of Notice of Privacy Practices: I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations. I give permission for this office to leave messages on any personal home phone, cell phone, or e-mail.

Signature:

Date:

If this consent is signed by a personal representative on behalf of the patient, complete the following:

Personal Representative’s Name:

Relationship to Patient: