THUAN-VU HO D.M.D.,MAY LIU D.D.S.

1690 Woodside Rd #118, Redwood City, CA 94061

650-365-1400

NEW PATIENT INFORMATION PACKET

DOCTOR’S NOTES ONLY:
Medical Alert:
Date:
Patient’s Full Name:
Nickname:
DOB:

PATIENT’S DENTAL HEALTH

What are your dental priorities ?
Please check all that apply:

PATIENT’S MEDICAL HISTORY

I consider my health to be (please select one):
Do you have or have had any of the following ?
AIDS
Allergies
Anemia
Arthritis
Artificial Joints
Artificial Heart Valves
Asthma
Blood Disease or Excessive Bleeding
Cancer
Chemical Dependency
Chemotherapy or Radiation Therapy
Circulatory Problems
Cortisone Treatments
Diabetes High or Low ?
Dizziness or Fainting
Dry Mouth
Epilepsy
Glaucoma
Headaches or Head Injuries
Hearing Problems
Hemophilia
Heart Disease
Heart Murmur
Hepatitis A, B or C
High Blood Pressure
HIV
Kidney Disease
Liver Disease
Low Blood Pressure
Mental Disorder or Psychiatric Care
Mitral Valve Prolapse
Nervous Disorder
Osteoporosis
Pacemaker
Pregnancy
Respiratory Problems or Shortness of Breath
Rheumatic Fever
Rheumatism
Scarlet Fever
Shunts
Sinus Problems
Skin Rash
Smoking of Tobacco Habit
Stomach Problems or Ulcers
Stroke or Heart Attack
If so how long ago
Swelling of Feet or Ankles
Thyroid Problems
Tonsilitis
Turberculosis or Positive TB Skin test
Tumors
Veneral Disease
Vision Problems/Wearing Glasses or Contact Lenses
Are you allegic to any of the following ?
Aspirin
Barbiturates (Sleeping Pills)
Codeine Allergy
Latex Allergy
Local Anesthetic Allergy
Penicillin Allergy
Phen Phen Allergy
Sulfa Allergy
Are you taking any of the following for osteoporosis ?
Fosamax
Boniva
Reclast
Actonel
Other:
Women Only
Birth Control Medication
Pregnant or Nursing ?
Do you have any other medical problems or medical history NOT listed on this form ?
Please list all medications you are currently taking:
Physician’s Name:
Phone #:
Address:
In the event of an emergency, please contact:
Name:
Relationship:
Phone #:
Name:
Relationship:
Phone #:

PATIENT’S CONSENT

  1. I, the undersigned, hereby authorize the doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the doctor to make a through diagnosis of my dental needs.
  2. I, also authorize the doctor to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy in connection with my treatment. I understand that using anesthetic agents embodies a certain risk. Furthermore, I authorize and consent that the doctor choose and employ such assistance as deemed appropriate to provide the recommended treatment.
  3. I understand that it is my responsibility to advise the doctor’s office of any changes in the information contained on this form.
  4. I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions truthfully and to the best of my knowledge.

Signature of Patient or Parent if Minor

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Date:

Signature of Doctor

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License Number
Date:

PATIENT’S HEALTH HISTORY UPDATES

Date:            Changes:      (Please initial) Patient Doctor          
License#:
License#:
License#:
License#:
License#:
License#:

PATIENT INFORMATION and AGREEMENT

Date:
Patient’s Full Name
Nickname
GETTING TO KNOW YOU AS OUR PATIENT
Sex:
DOB
Age:
Social Security#:
CDL#:
Home Address
City, State, Zip:
Phone/Cell:
Work#:
Email:
Marital Status
Spouse Name:
Patient’s Employer
Employer’s Address
RESPONSIBILITY PARTY
Name of Responsible Party:
Relationship to you:
CDL#
Employer of Reponsible Party (name and address):
DOB
SS#:
PRIMARY INSURANCE COVERAGE
Insurance Company:
Phone:
Subscriber’s Name:
Subscriber’s Sex
Subscriber’s Date of Birth
Subscriber’s Social Security#:
Patient’s Relationship to Subscriber
Subscriber’s Employer
Subscriber’s ID#:
Group#:
SECONDARY INSURANCE COVERAGE
Insurance Company:
Phone:
Subscriber’s Name:
Subscriber’s Sex
Subscriber’s Date of Birth
Subscriber’s Social Security#:
Patient’s Relationship to Subscriber
Subscriber’s Employer
Subscriber’s ID#:
Group#:
How did you hear about our office ?

AGREEMENT TO PAY

I agree for all services rendered on my behalf of my dependents. In the event that payment is not made within (30) days of receipt of statement, a service charge at the legal rate may be added to the past due balance. If collection services are required, I further agree to pay for all legal fees and costs incurred in connection therewith. I certify that all information is complete and correct. Prima Dental office may verify this information from which ever sources it deems necessary including but not limited to a consumer report which may contain records information. All fees incurred for dental treatment are my total and ultimate responsibility, regardless of any insurance I may have. I understand that dental insurance is a contract between the patient and the insurance carrier, and NOT between the insurance carrier and the dentists.

I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my dependents during the period of such dental care to third party and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for my services. In the event that my insurance does not provide benefits or provides a reduced benefit, I will be financially responsible to pay up to the agreed upon fee schedule. I hereby authorize the doctor to release all information necessary to secure the payment of benefits and the use of this signature on all insurance submissions.

I also acknowledge that I have received a copy of the Dental Materials Fact Sheet dated 2004.

Patient/Parent Signature:

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Date:
Relationship to Patient:

FINANCIAL POLICY

We welcome you to our family of dental care providers and we are committed to your treatment being successful. Please understand that payment of your bill is part of your treatment. The following is a statement of our financial policy which we require you to read and sign prior to any treatment.

Payment is expected as services are rendered. If you are covered by insurance, we expect payment for deductibles and co-payments on the date of service. We accept most insurances, Cash, Checks, Visa, Master Card, American Express, Discover or we offer a few Payment Plans which allows low monthly payments with prior credit approval.

For your convenience, we offer the following methods of payment. Please check the method of payment you wish to choose to settle your account:

Regarding insurance:

We are happy to extend the courtesy of billing your insurance company for you. However, in order to provide this service to you, we must have complete insurance information and confirmation of your coverage. It is your responsibility to fill out the necessary forms that give us all the insurance information required. If this information is not provided to us in a timely manner, we will be unable to bill your insurance company for you and you will be expected to pay in full for services rendered. If we have not received payment from your insurance company within 45 days of billing, the balance becomes your responsibility. Your insurance policy is a contract between you and and your insurance company and we are not a party to that contract. You will be expected to contact them directly if a problem should arise. We expect all balances to be cleared in less than 45 days.

Usual and Customary Rates:

Our practice is committed to providing the best treatment and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determinations of usual and customary rates. Please keep in mind that we can only estimate what your insurance will pay since each insurance company has their specific limitations and exclusions.

Usual and Customary Rates:

Our practice is committed to providing the best treatment and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determinations of usual and customary rates. Please keep in mind that we can only estimate what your insurance will pay since each insurance company has their specific limitations and exclusions.

Billing:

For all accounts over 45 days with patients’ amounts due, there will be a $10.00 billing fee or a finance charge of 1.5% per month, whichever is more. We assign all accounts over 120 days to a collection service for processing.

Should this account become past due, you agree to pay reasonable additional fees, including any and all collection agency, legal fees and/or court cost, necessary to collect this amount.

I agree to this financial policy, and I have read and received a copy of this statement.

THERE WILL BE A CHARGE OF $100.00 FOR CANCELLING ANY APPOINTMENT WITHOUT 48 HOURS NOTICE OR FOR FAILING TO SHOW FOR AN APPOINTMENT.

Patient Signature:

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Date:

Parent/ Guardian Signature

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Date:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

“you may refuse to sign this acknowledgement”
We are not able to bill your insurance without your signature

I, have received a copy of the office’s Notice of Privacy Practices.

Patient Signature:

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Date:

Parent/ Guardian Signature

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Date:

We attempt to obtain written acknowledgement of receipt of our Notice of Private Practices, but acknowledgement could not be obtained because: