Patient Form - Rollings Hills Family Dentistry

Dr. Rani Shina
Thank you for selecting our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet all your dental healthcare needs, please fill out this form completely in ink. IF you have any questions or need assistance, please ask us. We will be happy to help.
Preferred Name*
Date*

MonthDayYear
Date
Social Security Number*
Patient Information (Confidential)
Patient Name*

First NameLast Name
Birthdate*

MonthDayYear
Home Phone*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Email Address*
Cell phone*
Check appropriate box*

MinorSingleMarriedDivorcedWidowedSeparated
Patient’s employer*
Work phone*
Business address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Spouse/Parent’s name*
Employer*
Work Phone*
If patient is a student, name of school/college*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Whom may we thank for referring you?*
Person to contact in case of emergency*
Relationship*
Phone*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Responsible Party
Name of person responsible for this account*
Relationship to patient*
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone*
Driver’s license#*
Birthdate*

MonthDayYear
Social Security#*
Employer*
Work Phone*
Is this person currently a patient in our office?*

YesNo
Insurance Information
Name of Insured*
Relationship to Patient*
Birthdate*

MonthDayYear
Social Security#*
Date Employed*

MonthDayYear
Name of Employer *
Work Phone*
Address of Employer*

Street Address

Street Address Line 2

CityState

Zip Code
Insurance Company*
Group#*
Union or Local#*
Ins. Co. Address*

Street Address

Street Address Line 2

CityState

Zip Code
Ins. Co. Phone*
Max. Annual Benefit*
How much is your deductible*
I acknowledge that I have reviewed & offered a copy of this office’s Notice of Privacy Practices.
Patient Signature*

Clear
Date*

MonthDayYear
Date
I acknowledge that I have reviewed & offered a copy of the Dental Material Fact Sheet dated 10/17/2001.
Patient Signature*

Clear
Date*

MonthDayYear
Date
Patient Medical History
Patient Name*
Date*

MonthDayYear
Physician*
Office Phone*
Please enter a valid phone number.
Date of last exam*

MonthDayYear
1. Are you under medical treatment now?*

YesNo
2. Have you ever been hospitalized for any surgical operation or serious illness?*

YesNo
3. Are you taking any medications(s) including non-prescription medicine?*

YesNo
If yes, what medications(s) are you taking?
4. Have you ever taken Phen-fen?*

YesNo
5. Do you use tobacco?*

YesNo
6. Do you use alcohol?*

YesNo
7. Do you use cocaine or other drugs?*

YesNo
8. Are you wearing contact lenses?*

YesNo
9. Are you allergic to or had a reaction to the following:*

YesNo
Codeine*

YesNo
Local anesthetics (e.g. Novocain, Epinephrine) *

YesNo
Nitrous oxide*

YesNo
Penicillin or other antibiotics*

YesNo
Sulfa drugs*

YesNo
Sedatives*

YesNo
Iodine*

YesNo
Aspirin*

YesNo
Other*

YesNo
10. Do you have any of the following?*
High blood pressure*

YesNo
Low blood pressure*

YesNo
Kidney diseases*

YesNo
Tuberculosis*

YesNo
Cancer/tumor*

YesNo
Radiation therapy*

YesNo
Heart disease*

YesNo
Arthritis*

YesNo
Cardiac pacemaker*

YesNo
Joint replacement/implant*

YesNo
Liver disease*

YesNo
Heart murmur*

YesNo
Sexually trans. disease*

YesNo
Respiratory problems*

YesNo
Mitral Valve Prolapse*

YesNo
Hepatitis/jaundice*

YesNo
Easily winded*

YesNo
Rheumatic fever*

YesNo
AIDS or HIV infection*

YesNo
Emphysema*

YesNo
Fainting/seizures*

YesNo
Stomach troubles/ulcers*

YesNo
Asthma*

YesNo
Epilepsy/convulsions*

YesNo
Latex sensitivity*

YesNo
Frequently tired*

YesNo
Diabetes*

YesNo
Hay fever/allergies*

YesNo
Anemia*

YesNo
Stroke*

YesNo
Other*

YesNo
Women only:
a. Are you pregnant or think you may be?*

YesNo
If yes, # of month
b. Are you nursing?*

YesNo
Patient Dental History
What is your immediate dental concern?*
1. Are you satisfied with the appearance of your teeth?*

YesNo
2. Do your gums bleed while brushing or flossing?*

YesNo
3. Are your teeth sensitive to hot or cold liquids/foods?*

YesNo
4. Are your teeth sensitive to sweet or sour liquids/foods?*

YesNo
5. Do you feel pain to any of your teeth?*

YesNo
6. Do you have any sores or lumps in or near you mouth?*

YesNo
7. Have you had any head, neck or jaw injuries?*

YesNo
8. Have you ever experienced any of the following problems with your jaw? ( Clicking, Pain... )*

YesNo
a. Clicking?*

YesNo
b. Pain?*

YesNo
b. Pain?*

YesNo
c. Difficulty in opening or closing?*

YesNo
d. Difficulty in chewing?*

YesNo
9. Do you have frequent headaches?*

YesNo
10. Do you clench or grind your teeth?*

YesNo
11. Do you bite your lips or cheeks frequently?*

YesNo
12. Have you had your wisdom teeth removed?*

YesNo
13. Have you ever had any prolonged bleeding following extractions?*

YesNo
13. Have you had any orthodontic treatment?*

YesNo
14. Do you get food caught between any of your teeth?*

YesNo
15. Have you ever had nitrous oxide (laughing gas)?*

YesNo
16. Does your heart rate increase after administration of a local anesthetic?*

YesNo
Name of last dentist*
Date of last cleaning*

MonthDayYear
Date
Date of last x-rays*

MonthDayYear
Date
Authorization and Diagnostic consent
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. The undersigned hereby authorizes the doctor and staff members to take x-rays, study models, photographs, or any other diagnostic aid deemed necessary by the doctor to make a thorough diagnosis of the patient's dental needs. I understand that the doctor will explain his diagnosis to me before treatment is done. I understand the responsibility for payment of dental services provided in this office for my dependents or myself is mine. I further understand that payment is due and finance charge (18%) annually will be added to any balance over 45 days. In the event of default, I promise to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees as may be required to affect collection of this balance.
Signature of patient, guardian or parent if minor*

Clear
Date*

MonthDayYear
Date
Financial Policy
Dr. Rani Shina, D.D.S,, Inc.

Welcome! We are pleased you have selected us to assist you with your dental needs. Our aim is to provide you with personalized quality dental care. If you have any questions regarding your treatment, please bring it to our attention. We would like to introduce you to our office financial policy.

Payment for service is required at the time of your visit. This helps to reduce our overhead costs resulting in lower fees for our patients. For your convenience, we accept cash, checks, MasterCard, Visa, Discover, and American Express.

If you have dental insurance, we will be happy to assist you in filing a claim and in determining your benefits. Bring your insurance card and booklet with you for your first visit. We will keep it on file for subsequent visits.Please notify us of any changes in your coverage.

All co-payments and deductibles are due when services are rendered. You are directly responsible to our office for payment of your account regardless of the status of your insurance claim. You will receive a statement each month for our office even though your insurance is pending. The estimate provided by this office is to be used only as a guideline until the final insurance payment is received and the patient’s account has been reconciled. *An estimate is no guarantee of the insurance payment, and is clearly stated by the insurance company. However, we are here to assist you, to receive the best care and the most from your benefits.

If we have filed your insurance claim on you behalf and no payment or a “denial of benefits” notice has been received within thirty days, we encourage you to contact your insurance company as to the reason for the delay.

*If your insurance has not paid within 45 days, we will require that you clear your balance. Meaning, you must pay off your account in full and instruct your insurance company to reimburse you directly. See below.

Please be advised that if NO payment is received within 30 days of your statement, and 18% interest rate will be assessed to the balance.

We are happy to work with patients who do not have insurance. Financial arrangements may be available for large cases on an individual basis.

The best dental care can be provided only on the basis of mutual understanding. We, therefore, encourage our patients to discuss any questions they may have regarding our financial policy with our Practice Administrator.

There will be a $50.00 cancellation fee per hour of scheduled time if cancelled with less then 24 hours notice given.
Signature

Clear
Print Name *Patient or Responsible Party Signature Signature* Date Date*
*I understand that 1 am directly responsible for all dental services rendered regardless of the status of the insurance benefits should my account go over 45 days from date of service. In the event that the insurance benefits should fall short of the estimated amount, you authorize us to place the amount due on the following credit card.
Should be Empty:

Dr. Rani Shina

Patient Information (Confidential)

Responsible Party

Insurance Information

Patient Medical History

Patient Dental History

Authorization and Diagnostic consent

Financial Policy

Dr. Rani Shina, D.D.S,, Inc.