General Patient Information

Dr.

Mr.

Mrs.

Ms.

First name minimum length should be 2 characters

Middle name minimum length should be 2 characters

Last name minimum length should be 2 characters

Nick name minimum length should be 2 characters

Sex*

M

F

Please enter a valid social security

Please enter a valid age

Please enter a valid date

Please enter a valid street

Please enter a valid city

Please enter a valid state

Please enter a valid zip code

Please enter a valid phone number

Please enter a valid phone number

Have you ever been a patient of our practice?*

No

Yes

Only alphabets with not less than 4 and more than 150 allowed

Only alphabets with not less than 4 and more than 150 allowed

Valid format is Example@Example.com

Only Alphabets with not less than 4 and more than 150 allowed

Please enter a valid phone number

Person Legally Responsible For Account (If Under 18)

Who will be responsible for your account?

Self

POA

Spouse

Father

Mother

Other

Name minimum length should be 2 characters

Name minimum length should be 2 characters

Please enter a valid social security number

Please enter a valid date

Please enter a valid phone number

Please enter a valid street

Please enter a valid city

Please enter a valid state

Please enter a valid Zip Code

Name minimum length should be 2 characters

Please enter a valid phone number

No Dental

No Medical

Insurance Information

Primary Dental Insurance

Name minimum length should be 2 characters

Minimum length should be 2 characters

Sex

M

F

Please enter a valid date

Please enter a valid phone number

Social Security is a 9 digits value

Minimum length should be 2 characters

Please enter a valid phone number

Please enter a valid insurance company name

Please enter a valid group

Please enter a valid ID

Please enter a valid Address

Primary Dental Insurance Card Images

Primary Dental Insurance Card Front

No File Chosen

Primary Dental Insurance Card Back

No File Chosen

Insurance Information

Primary Medical Insurance

Minimum length should be 2 characters

Minimum length should be 2 characters

Sex

M

F

Please enter a valid DOB

Please enter a valid phone number

Social security number is a 9 digits value

Minimum length should be 2 characters

Please enter a valid phone number

Please enter a valid Ins Co. Name

Please enter a valid group

Please enter a valid ID

Please enter a valid insurance card address

Primary Medical Insurance Card Images:

Primary Medical Insurance Card Front

No File Chosen

Primary Medical Insurance Card Back

No File Chosen

Insurance Information

Secondary Dental Insurance

Minimum length should be 2 characters

Minimum length should be 2 characters

Sex

M

F

Please enter a valid date

Please enter a valid phone number

Please enter a valid 9 digits value

Minimum length should be 2 characters

Please enter a valid phone number

Please enter a valid ins company name

Please enter a valid group

Please enter a valid ID

Secondary Dental Insurance Card Images

Secondary Dental Insurance Card Front

No File Chosen

Secondary Dental Insurance Card Back

No File Chosen

Insurance Information

Secondary Medical Insurance

Minimum length should be 2 characters

Minimum length should be 2 characters

Sex

M

F

Please enter a valid Date

Please enter a valid phone

Please enter a valid 9 digits number

Minimum length should be 2 characters

Please enter a valid phone number

Please enter a valid ins company name

Please enter a valid group

Please enter a valid ID

Please enter a valid Date

Secondary Medical Insurance Card Images:

Secondary Medical Insurance Card Front

No File Chosen

Secondary Medical Insurance Card Back

No File Chosen

Please enter a valid Initial

History

Patient name minimum length should be 2 characters

Patient middle name minimum length should be 2 characters

Patient last name minimum length should be 2 characters

Please enter a valid date

Sex*

M

F

Please enter a valid age

Please enter a valid date of birth

Please enter a valid 9 digits social security number

Please enter a valid Emergency Contact

Please enter a valid relationship value

Home Please enter a valid phone number

Please enter a valid phone number

Please enter a valid dentist name

Please enter a valid reason

Patient Please enter a valid phone number

Please enter a valid value

For the following questions, check yes or no, whichever applies. Your answers are for our records only and will be considered confidential.

3A. Are you under the care of a physician?*

Yes

No

Please enter a valid Date

Please enter a valid value

3B. Do you take or have you ever taken or been given any of the following medications? (Check those that apply.)

Fosomax

Actonel

Boniva

Aredia (IV)

Zometa (IV)

Prolia

Reclast

Date Started

Please enter a valid Date

Date Discontinued

Please enter a valid Date

4. Are you allergic to or have you had an allergic reaction to any of the following?*

Local anesthetics

Yes

No

Iodine

Yes

No

Penicillin or antibiotics

Yes

No

Codeine or other narcotics

Yes

No

Barbiturates or sleeping pills

Yes

No

Latex or rubber products

Yes

No

Aspirin or ibuprofen

Yes

No

Other

Yes

No

5. Have you had any surgery, serious illness, or hospitalization in the past?*

Yes

No

If so, please list:

Please enter a valid Date

Please enter a valid Date

6. Have you or any family members had any serious reactions to IV sedation or general anesthesia?*

Yes

No

If so, explain:

Please enter a valid Date

7. Do you have or have you had any of the following diseases or problems?

Damaged Heart Valves. Artificial Valves, or Heart Murmur

Yes

No

History of Snoring, Sleep Apnea, or Use of CPAP

Yes

No

Rheumatic Heart Disease

Yes

No

Heart Attack, Heart Surgery. or Irregular Heartbeat

Yes

No

High Blood Pressure

Yes

No

Asthma, Hay Fever, or Allergies

Yes

No

Emphysema, Bronchitis. Etc

Yes

No

Sinus Trouble

Yes

No

Tuberculosis

Yes

No

Stomach Ulcer or Frequent Heartburn

Yes

No

Liver Trouble (Hepatitis, Jaundice, or Liver Disease)

Yes

No

Kidney Trouble

Yes

No

Diabetes

Yes

No

Thyroid Problems

Yes

No

Arthritis or Painful, Swollen Joints Including Jaw Joint (TMJ)

Yes

No

Seizures (Epilepsy), Stroke, or Neurological Disorder

Yes

No

Any Disease, Drug, or Transplant Operation that has Suppressed your Immune System

Yes

No

Have you taken any steroid medications in the past two years

Yes

No

8. Do you have any blood disorders?

Yes

No

Anemia

Yes

No

Have you ever required a blood transfusion?

Yes

No

Abnormally prolonged bleeding (e.g., hemophilia)

Yes

No

Are you taking any blood thinners?

Yes

No

9. Do you have any artificial joints (hip, knee, shoulder. etc.)?

Yes

No

10. Have you ever been treated for glaucoma?

Yes

No

11. Have you ever had treatment for a tumor or cancer?

Yes

No

Radiation therapy involving the mouth, face, or neck

Yes

No

Chemotherapy

Yes

No

12. Do you smoke, or have you ever smoked?

Yes

No

If yes, how much?

Please enter a valid Date

For how long?

Please enter a valid Date

Quit when?

Please enter a valid Date

13. Have you ever been treated for alcohol or other substance abuse?

Yes

No

If yes, for what?

Please enter a valid Date

When?

Please enter a valid Date

14. Have you ever or do you currently use any recreational/illicit drugs?

Yes

No

If yes, for what?

Please enter a valid Date

15. Have you had a cold, flu, sore throat, sinus infection, or other respiratory tract infection in the past week?

Yes

No

16. Do you have any other concerns or diseases you think the doctor should know about?

Yes

No

If so, explain:

Please enter a valid Date

17. Do you wish to talk with the doctor privately about anything?

Yes

No

Are you pregnant or trying to become pregnant?

Yes

No

Are you nursing (breastfeeding)?

Yes

No

Are you taking birth control pills?

Yes

No

If you're using oral contraceptives, it is important to understand that antibiotics (and some other medications) interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance.

Please enter a valid Initial

What is the reason of your dental visit?

Please enter a valid visit

Have you ever had a serious injury to your head or mouth?

Yes

No

Do you have earaches or neck pains?

Yes

No

Do you wear dentures or partials?

Yes

No

Who is your general dentist?

Please enter a general dentist

Date of last dental exam?

Please enter a date of last dental exam

Procedure done?

Please enter a procedure done

Date of last dental x-rays taken?

Please enter a date of last dental x-rays taken

Please check the appropriate box in answer to the following questions.

Do your gums or teeth hurt now?

Yes

No

Not Sure

Do your gums bleed?

Yes

No

Not Sure

Are you aware of a bad taste or odor in your mouth?

Yes

No

Not Sure

Have you had gum boils or abscesses within the past three months?

Yes

No

Not Sure

Have you had a toothache within the past three months?

Yes

No

Not Sure

Are any of your teeth particularly sensitive to hot or cold?

Yes

No

Not Sure

Do you have frequent blisters or canker sores on your lips or mouth?

Yes

No

Not Sure

Have you ever had a burning sensation of the tongue?

Yes

No

Not Sure

Does your jaw ever get "out of joint", "click", or cause pain?

Yes

No

Not Sure

Do you clench or grind your teeth?

Yes

No

Not Sure

Have you ever had periodontal (gum) treatment?

Yes

No

Not Sure

If yes, when?:

Please enter a valid value

Have you ever been treated by a periodontist?

Yes

No

Not Sure

If yes, when?:

Please enter a valid value

Have you ever had orthodontic treatment (braces)?

Yes

No

Not Sure

If yes, when?:

Please enter a valid value

Are you unusually apprehensive about dental treatment?

Yes

No

Not Sure

Do you clean between your teeth?

Yes

No

Not Sure

If yes, with what?:

Please enter a valid value

Have you ever been shown how to use dental floss?

Yes

No

Not Sure

Have you had any teeth extracted within the past five years?

Yes

No

Not Sure

If yes, how many?

Please enter a valid value

How often do you brush your teeth?

Please enter a valid value

What type of tooth brush do you use (hard, medium, soft)?

Please enter a valid value

When were your teeth last "cleaned" by a dentist or dental hygienist?

Please enter a valid value

How frequently have your teeth been "cleaned" by a dentist or a dental hygienist in the last five years?

Please enter a valid value

Acknowledgment of Receipt of Statement of Privacy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Menominee Advanced Periodontics & Implant Center. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office healthcare operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Menominee Advanced Periodontics & Implant Center reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

Additional Disclosure Authorization*

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected healthcare information to the person(s) identified below. (I understand that the default answer is NO. Without indicating YES in answer to each individual question, personal protected healthcare information [PHI] cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

Spouse Only:

Yes

No

Any Member of My Immediate Family (e.g., Spouse, Children, Siblings, etc.)

Yes

No

Any Member of My Extended Family (e.g., Parents, Grandchildren, etc.)

Yes

No

Other

Yes

No

If yes:

Please enter a valid Date

Please enter a valid Date

Additional Disclosure Authorization*

By signing below you are confirming the General Patient Information and Health History has been filled out accurately and to the best of your ability. Your signature is also confirming that you have read and understood the Financial Agreement and Acknowledgment of Receipt of Statement of Privacy Practices and Additional Disclosure Authorization.

Please enter a valid date

Sex*

M

F

Please enter a valid age value

Patient's (or Legal Guardian's) Signature*

Please sign form before submitting

Registration sent successfully

Authorization for use and release of periodontal information for research, education, and promotional purposes

Periodontist’s Name

Shorouk Elnagdy

4103 10th St Menominee MI 49858
Periodontist’s Address City State Zip

Patient’s full name at the time of treatment:

Please enter a valid Patient Name

I authorize the use and disclosure of any or all of my periodontal records, including but not limited to my name, photos, records, slides, x-rays, and other viewings of my care and treatment before and after completion of procedures for research, education, and promotional purposes.

  • I understand that I may refuse to sign this authorization and that the periodontist may not condition my treatment on whether I provide this authorization.
  • I understand that this authorization will expire one year after the date of my death.
  • I understand that no recipient of my periodontal information is covered by the federal privacy regulations that protect the privacy of healthcare information, and that after its release, my information will be subject only to the recipient’s privacy policies and not to federal law.
  • I understand that I may receive a copy of this authorization by submitting a request to the periodontist at the address noted on the top of this form.

Please enter a valid date

Please enter a valid Relationship

Signature of Patient or Authorized Person

Please sign form before submitting

Registration sent successfully

FINANCIAL POLICY

As an out-of-network provider, we want to ensure that you fully understand the financial responsibilities associated with receiving services at our practice. Please take a moment to review the following details:

1. Understanding Out-of-Network:

By receiving care from our office, you are acknowledging that we are an out-of-network provider for your insurance plan. This means your insurance may not cover the full cost of your treatment, and you will be responsible for paying the total service fee.

2. Payment Responsibility:

You are 100% responsible for the service fee at the time of your appointment. The full payment will be due on the day of service, or prior to the appointment.

3. Courtesy Claims to Insurance:

We will file a courtesy claim to your dental insurance only if we have complete and accurate information about your policy, and only if the service provided is eligible to be filed with dental insurance. Please note that biopsies cannot be filed to dental insurance.

4. Financing Options:

If you require financing, we offer a 0% interest payment plan for 6 months, with the requirement that half of the total service fee is paid on the day of service. Additionally, we accept CareCredit, a third-party financing option that offers more flexible payment plans. If you are interested in CareCredit, you must apply and be approved prior to services being rendered.

Payment for services is due at the time of the service unless other arrangements have been made prior to treatment. Payments may be made using cash, check, or credit cards. As a courtesy, we are happy to submit the claims necessary to see that you receive your benefits. The insurance contract is an agreement between you and the insurance company. You are ultimately responsible for all charges. We cannot guarantee that any coverage estimated by your plan will be paid once a claim is filed. You are responsible for payment of all services regardless of the payable benefit.

Checks that are returned to our office from your financial institution are subject to a $30.00 returned check fee*. This fee covers the processing fees that are charged to our office. We would be happy to discuss our charges and how they relate to your particular situation. Please indicate your understanding and acceptance of these financial policies by signing below.

Please enter a valid date

Please enter a valid Patient Name

Patient signature

Please sign form before submitting

Parent/Legal Guardian name and signature:

Please sign form before submitting

Registration sent successfully

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.

THIS NOTICE APPLIES TO ALL OF THE RECORDS OF YOUR CARE GENERATED BY THE PRACTICE, WHETHER MADE BY THE PRACTICE OR AN ASSOCIATED FACILITY.

OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this notice about our privacy practices, our legal duties and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice takes effect / / and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this notice at any time provided such changes are permitted by applicable law. We reserve the right to make changes in our privacy practices and the new terms of our notice effective for all health information that we maintain including health information we created or received before we made the changes. Before we make a significant change in our privacy practices we will change this notice and make the new notice available upon request.

You may request a copy of our notice at any time. For more information about our practices or for additional copies of this notice please contact us using the information listed at the end of this notice.

USEES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment payment and healthcare operations. For example:

TREATMENT: We may use or disclose your health information to a physician or other health care provider providing treatment to you.

PAYMENTS: We may use and disclose your health information to obtain payment for services we provide to you.

HEALTH CARE OPERATIONS: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities. Reviewing the competence or qualifications of health care professionals, evaluating practitioners and provider performance conducting training programs accreditation, certification, licensing or credentialing activities.

YOUR AUTHORIZATION: In addition to our use of your health information for treatment payment or health care operations you may give us written authorization to use your health information or to disclose it to anyone for any purpose if you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while in effect. Unless you give us a written authorization we cannot use or disclose your health information for any reason except those described in this notice.

TO YOUR FAMILY AND FRIENDS: We must disclose your health information to you as described in this patient rights section of this notice. We may disclose your health information to a family member, friend, or another person to the extent necessary to help with your health care or with payment for your healthcare, but only if you agree that we may do so.

PERSONS INVOLVED IN CARE: We may use or disclose health information to notify or assist in the notification of including identifying or locating a family member your personal representative or another person responsible for the care of your location, your general condition, or death. If you are present then prior to the use or disclosure of your health information we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practices to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x- rays, or other similar forms of health information.

MARKETING HEALTH-RELATED SERVICES: We will not use your health information for marketing communications without your written authorization.

REQUIRED BY LAW: We may use or disclose your health information when we are required to do so by law.

ABUSE OR NEGLECT: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, domestic violence, or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIV ACY PRACTICES

** You may refuse to sign this acknowledgment **

did receive a copy of this office's Notice of Privacy Practices on.

Patient Signature

Please sign form before submitting

Registration sent successfully

BELOW LINE FOR OFFICE USE ONLY


We attempted to obtain written acknowledgement of receipt of our Notice of Privacy
Practices, but it could not be obtained because:

Individual refused to sign

Communications barriers prohibited obtaining the acknowledgement

An emergency situation prevented us from obtaining

Other (please specify)

Registration sent successfully

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