Patient Form | Sunny E. Kim DDS

New Patient Registration

(Fields marked with * are required)

First name

Last name

Preferred Name

Date Of Birth

Driver's License Number

SSN

Address

Address (optional)

City

State

Zip

Primary Phone

Work Phone

Emergency Phone

Employer

Occupation

Employment Status

Previous dentist’s name and city/state

Referred By

Responsible Party (if someone other than patient)

Relation To Patient

First name

Last name

Preferred Name

Date Of Birth

Driver's License Number

SSN

Address

Address (optional)

City

State

Zip

Primary Phone

Work Phone

Emergency Phone

Employer

Occupation

Employment Status

Referred By

Insurance Information

(Fields marked with * are required)

Insurance Company Name

SSN or ID Number

Group Number

Policy Holder First Name

Policy Holder Last Name

Policy Holder Date of Birth

Address

Address (optional)

City

State

Zip

Employer

Occupation

Employment Status

Secondary Insurance Information

Insurance Company Name

SSN or ID Number

Group Number

Policy Holder First Name

Policy Holder Last Name

Policy Holder Date of Birth

Address

Address (optional)

City

State

Zip

Employer

Occupation

Employment Status

Health History

(Fields marked with * are required)

Are you currently being treated by a physician?

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 you 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 get pregnant?

Yes No

Nursing?

Yes No

Taking oral contraceptives?

Yes No

Are you allergic to any of the following?

(Fields marked with * are required)

Aspirin

Yes No

Penicillin

Yes No

Codeine

Yes No

Acrylic

Yes No

Metal

Yes No

Latex

Yes No

Sulfa Drugs

Yes No

Local Anesthetics

Yes No

Other

Yes No

If Yes:

Do you have, or have you had, any of the following?

(Fields marked with * are required)

Have you ever had any serious illness not listed?

Yes No

If Yes:

Comments

Terms And Conditions

(Fields marked with * are required)

Terms

Terms *

I understand that the information that I have given today is correct to the best of my knowledge and that providing incorrect information can be dangerous to my (or patient's) health. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform the office of any changes in my medical status. I hereby authorize the release of any information pertaining to my medical treatment necessary to process any insurance claims. I further authorize the application for benefits on my behalf for covered services and payment of any benefits to the office. I understand that I am responsible for any amount not covered by insurance. I understand that where appropriate, credit bureau reports may be obtained.

Release Authorization

(Fields marked with * are required)

I authorize Sunny E. Kim DDS and office staff to release or request my medical and/or billing information to the following individuals:

HIPAA and Privacy Practices Consent

(Fields marked with * are required)

HIPAA Consent

HIPAA Consent *

I give this practice/ clinic my consent to use or disclose my protected health information to carry out my treatment, to obtain payment from insurance companies, and for health care operations like quality reviews. I give this practice consent to leave messages with household members and answering machines when necessary. I have been informed that I may review the practice's "Notice of Privacy Practices" (for a more complete description of uses and disclosures) before signing this consent. I understand that this practice has the right to change their Privacy Practices and that I may obtain any revised notices at the practice. I understand that I have the right to request a restriction of how my protected health information is used. However, I also understand that the practice is not required to agree to the request. If the practice agrees to my requested restriction, they must follow restriction(s). I also understand that I may revoke this consent at any time by making a request in writing, except for information already used or disclosed.

Signature

(Fields marked with * are required)

Signature

Online Patient Form

New Patient Registration

Responsible Party (if someone other than patient)

Insurance Information

Secondary Insurance Information

Health History

Are you allergic to any of the following?

Do you have, or have you had, any of the following?

Terms And Conditions

Release Authorization

HIPAA and Privacy Practices Consent

Signature

Opening Hours

Navigation

About Us

Online Patient Form

New Patient Registration

Responsible Party (if someone other than patient)

Insurance Information

Secondary Insurance Information

Health History

Are you allergic to any of the following?

Do you have, or have you had, any of the following?

Terms And Conditions

Release Authorization

HIPAA and Privacy Practices Consent

Signature

Opening Hours

About Us

We value your privacy