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Forms

Medical History

Physician
Date of Last Visit
MM slash DD slash YYYY
Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Are you taking any medication? If so, which ones?*
Have you had any major operations?*
Have you ever been involved in a serious accident?*
Select any of the medical conditions below that you have had or currently have:*
Are there any medical conditions we have not discussed that you feel we should be made aware of?*
Signature of Responsible Party*
I certify the above information is true and correct to the best of my knowledge.
First Last
Signature

HIPAA

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES *Please Note: I may refuse to sign this acknowledgment. I have been offered and/or received a copy of Drs. Kirkpatrick and Lai's Notice of Privacy Practices. I understand that my PHI (Protected Health Information) can and will be used for purposes of treatment and for payment from both myself and/or third party. I understand that I may request a copy of the privacy policies at any time.*

Printed Patient Name:
Date
MM slash DD slash YYYY
Hidden
Patient Signature (18+ years of age)
Patient Signature (18+ years of age)
Hidden
Parent/Guardian Signature*
Parent/Guardian Signature*
Relationship to Patient*
Name and relationship for each person to whom you authorize release of information to:
Expires 3 Years from Initial Signature*
Date:
MM slash DD slash YYYY
Expires when patient reaches the age of 18*
Date of Age 18:
MM slash DD slash YYYY

Insurance Form

Primary Policyholder/Subscriber Information
Policyholder/Subscriber Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Gender*
Policyholder ID/SSN*
Insurance Company*
Plan/Group Number*
Employer Name*
Change of Insurance
- New Plan
- New Employer
Do you have Secondary Insurance?*
- Yes
- No
Secondary Policyholder/Subscriber Information
Policyholder/Subscriber Name*
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Gender*
Policyholder ID/SSN*
Insurance Company*
Plan/Group Number*
Change of Insurance
- New Plan
- New Employer
Employer Name*
Patient Information
Relationship to Policyholder/Subscriber*
Patient Name*
First Last
Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Date of Birth*
MM slash DD slash YYYY
Gender*
Authorizations
I have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with this claim.*

Parent/Guardian Name
Signature
Date*
MM slash DD slash YYYY
I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the below named dentist or dental entity.*

Parent/Guardian Name
Signature
Date*
MM slash DD slash YYYY