* indicates a required field Step 1 of 4 25% Patient RegistrationResponsible Party InformationFirst Name:* Last Name:* Middle Initial: Address:* Address 2: City:* State:*Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip:* Home Phone:Cell Phone:Work Phone:Ext: Pager: Birth Date:* MM slash DD slash YYYY Soc Sec: Driver's Lic: Check Appropriate Box: Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder Patient InformationSection 1Address: Address 2: City: State:Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip: Home Phone:Cell Phone:Work Phone:Ext: Pager: Sex:* Male Female Marital Status* Married Single Divorced Separated Widowed Birth Date:* MM slash DD slash YYYY Age:* Soc Sec: Driver's Lic: Email:* I would like to receive correspondences via email:* Yes No Section 2Employment Status: Full Time Part Time Retired Student Status: Full Time Part Time Not Applicable Medicaid ID: Pref. Dentist: Pref. Hyg: Pref. Pharmacy: Employer ID: Employer ID: Section 3Referred By: Previous Dentist: Emergency Contact: Emergency Contact #:Primary Insurance InformationName of Insured: Relationship to Insured: Self Spouse Child Other Insured Soc. Sec: Insured Birth Date: MM slash DD slash YYYY Employer: Address: Address 2: City: State:Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip: Ins. Company: Address: Address 2: City: State:Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip: Rem. Benefits: Rem. Deduct: Secondary Insurance InformationName of Insured: Relationship to Insured: Self Spouse Child Other Insured Soc. Sec: Insured Birth Date: MM slash DD slash YYYY Employer: Address: Address 2: City: State:Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip: Ins. Company: Address: Address 2: City: State:Please SelectAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip: Rem. Benefits: Rem. Deduct: Signature:*Date:* MM slash DD slash YYYY Medical HistoryPatient Name:* Birth Date:* MM slash DD slash YYYY Date Created:* MM slash DD slash YYYY Are you under a physician's care now?* 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 Do you use tobacco?* Yes No Do you use controlled substances?* Yes No If yes: Are you taking blood thinners?* 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?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 other, explain: Do you have, or have you had, any of the following?AIDS/HIV* Yes No Alzheimer disease* Yes No Anaphylaxis* Yes No Anemia* Yes No Angina* Yes No Arthritis* Yes No Artificial heart valve* Yes No Artificial joint* Yes No Asthma* Yes No Blood disease* Yes No Blood transfusion* Yes No Breathing problems* Yes No Bruise easily* Yes No Cancer* Yes No Chemotherapy* Yes No Chest pains* Yes No Cold sores* Yes No Congenital heart disorder* Yes No Convulsions* Yes No Cortisone medicine* Yes No Diabetes* Yes No Drug addiction* Yes No Easily winded* Yes No Emphysema* Yes No Epilepsy or seizures* Yes No Excessive bleeding* Yes No Excessive thirst* Yes No Fainting spells* Yes No Frequent cough* Yes No Frequent diarrhea* Yes No Frequent headaches* Yes No Genital herpes* Yes No Glaucoma* Yes No Hay fever* Yes No Heart attack* Yes No Heart murmur* Yes No Heart pacemaker* Yes No Heart trouble* Yes No Hepatitis A* Yes No Hepatitis B or C* Yes No Herpes* Yes No High blood pressure* Yes No High cholesterol* Yes No Hives or rash* Yes No Hypoglycemia* Yes No Irregular heartbeat* Yes No Kidney problems* Yes No Leukemia* Yes No Liver disease* Yes No Low blood pressure* Yes No Lung disease* Yes No Mitral valve prolapse* Yes No Osteoporosis* Yes No Pain in jaw joints* Yes No Parathyroid disease* Yes No Psychiatric care* Yes No Radiation treatments* Yes No Recent weight loss* Yes No Renal dialysis* Yes No Rheumatic fever* Yes No Rheumatism* Yes No Scarlet fever* Yes No Shingles* Yes No Sickle cell disease* Yes No Sinus trouble* Yes No Spina bifida* Yes No Stomach intestinal disease* Yes No Stroke* Yes No Swelling of limbs* Yes No Thyroid disease* Yes No Tonsillitis* Yes No Tuberculosis* Yes No Tumors or growths* Yes No Ulcers* Yes No Venereal disease* Yes No Yellow jaundice* Yes No Have you ever had any serious illness not listed above?* Yes No If yes, explain: Comments:PATIENT SIGNATURE To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.Signature of Patient, Parent or Guardian:*Date* MM slash DD slash YYYY Authorization for Use Or Disclosure Of Patient Photography and/or Video ImagesAuthorization: I authorize the use and disclosure of my name, photography, video images, and testimonial for marketing purposes by the practice listed. I understand that information disclosed pursuant to this authorization may be subject to disclosure and may no longer be protected by HIPPA privacy Regulations.Purpose: The photographic/ video images, and or testimonial will be used for the following: Dental Records, dental research, dental education including lectures seminars, demonstrations, publications such as journals or books, and marketing material including websites and printed materials, patient education, and social media. Revocability: I understand that I may revoke this authorization at any time but such revocation must be in writing and received by the practice via registered mail. Revocation affects disclosure moving forward and is not retroactive this authorization expires 99 years from date signed.No Treatment Conditions: I understand that the practice cannot condition treatment on whether or not I sign this recognition.Patient Information:Patient Name:* If Personal Representative or Patient is a Minor:Patient name: - OR -Check here if you do not want your full face shot used for any of the above purposes. Don't use my face shot for any of the above purposes Patient Name: SIGNATURESignature of Patient/Legal Guardian:*Date:* MM slash DD slash YYYY General Consent FormSECTION A: PATIENT INFORMATIONName of Patient:* Date of Birth:* MM slash DD slash YYYY Last 4 Digits of SSN XXXX* SECTION B: CONSENT TO TREATMENT I do hereby authorize and request the performance of dental services for me and the use of whatever procedures Dr. Yun or his associates may deem necessary for treatment. I understand that Suk Jun Yun, DDS will use clinical and patient management techniques that are reasonable, necessary and advisable. I also authorize the administration of anesthetics or analgesics which may be deemed advisable to Suk Jun Yun, DDS. I understand that any treatment plans presented, along with the fees outlined, could change depending on the time elapsed since the initial examination and extent of dental pathology. Occasionally, once the treatment plan has been started, complications may arise which dictate additional procedures or treatment. Northpointe Family Dental will always advise me of any changes. In the event that any team member at Northpointe Family Dental is exposed to my blood or other bodily fluids, I agree to have my blood drawn and tested for Hepatitis B virus (HBV), Hepatitis C virus (HCV), and the human immunodeficiency virus (HIV). I understand that this testing would be done in a confidential manner, and would be made available only to the person who was exposed, and that person would be advised of my rights regarding protected health information.SECTION C: FINANCIAL RESPONSIBILITY I agree to be responsible for full payment of all charges for dental services performed on me. if for any reason the insurance company does not pay their estimated portion, I agree that I will be responsible for the account. In the event that my account is placed with a third party collection agency or attomey, I will be assessed any fees relating to this action.SECTION D: CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION I have been offered a copy of and have had full opportunity to read and consider your Notice of Privacy Practices. This Notice provides a description of treatment, payment activities and healthcare operations, of the uses and disclosures that we may make of your protected health information, and of other Important matters about your protected health information. I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information as described on the Notice of Privacy Practices to carry out treatment, payment activities and health care operations.Signature of Patient/Legal Guardian:*Date:* MM slash DD slash YYYY If the patient Is a minor, or If this Consent Is signed by a personal representative on behalf of the patient, please complete the following:Printed name of Parent, Guardian or Personal Representative: Relationship to Patient: Date: MM slash DD slash YYYY YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.CAPTCHAEmailThis field is for validation purposes and should be left unchanged.
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