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Dr. Amir Larijani
Dr. Alexander Choe
Dr. Morvarid Madani
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Reza Larijani MBA
Eddie Arreola, DA
Tamiko Williams, RDA
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(949) 459-9300
Patient Form
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Step
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Patient Information
We appreciate the confidence you have placed with us to provide Dental Care to you. All information on this chart is necessary for our records and is strictly confidential.
Patient Name
*
MI
Last
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DOB
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Address
*
Address Line 1
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Home Phone
*
Work Phone
Cell Phone
*
Email
*
SSN
*
In case of emergency, contact (Please specify someone not living in your household)
Name
*
Relationship to Patient
*
Home Phone
*
Work Phone
Cell Phone
*
Referral information
Please let us know how you heard about us.
*
Friend/Relative
Insurance Company
Signage
Website
Social Media
Advertisement
Other
Insurance information
Do you have Dental Insurance ?
No
Yes
Policy Holder Information
Name
*
MI
*
Last
*
DOB
*
MM
1
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Relationship to Patient
*
SSN
*
Dental Insurance Company
*
Phone
*
Insurance ID Number
*
Group Number
*
Assignment and Release
Name
*
Relationship to Patient
*
Signature
*
Clear Signature
Date
*
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Next
What is the reason for your visit today?
*
Are you in pain now?
*
No
Yes
Date of your last dental visit?
*
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Last Dental Cleaning
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Last Full Mouth X-Rays
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Previous Dentist’s name:
*
Address
Address Line 1
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
How often do you have dental examinations?
*
How often do you brush your teeth?
*
How often do you floss?
*
What other dental aids (waterpik, Electric toothbrush) do you use ?
*
Do you prefer to save your teeth?
Yes
No
Do you take fluoride supplements?
Yes
No
Have you had a special coating applied to your back teeth to protect them from tooth decay?
Yes
No
Do you think your dental health effects
Yes
No
Your over all health?
Yes
No
Do you think it is important to have your teeth cleaned at least every six months?
Yes
No
Do you drink coffee or tea?
Yes
No
If I could change my smile I would make my teeth:
*
Whiter
Repair Chipped teeth
Straighter
Replace old crowns/caps that don't match
Close Spaces
Replace dark old fillings
Crowded teeth
Less Gums showing
On a Scale of 1 to 10, with 10 being the highest rating
How important is your dental health?
*
Rate 1 out of 10
Rate 2 out of 10
Rate 3 out of 10
Rate 4 out of 10
Rate 5 out of 10
Rate 6 out of 10
Rate 7 out of 10
Rate 8 out of 10
Rate 9 out of 10
Rate 10 out of 10
Where would you rate your current dental health?
*
Rate 1 out of 10
Rate 2 out of 10
Rate 3 out of 10
Rate 4 out of 10
Rate 5 out of 10
Rate 6 out of 10
Rate 7 out of 10
Rate 8 out of 10
Rate 9 out of 10
Rate 10 out of 10
Where would you like your health to be?
*
Rate 1 out of 10
Rate 2 out of 10
Rate 3 out of 10
Rate 4 out of 10
Rate 5 out of 10
Rate 6 out of 10
Rate 7 out of 10
Rate 8 out of 10
Rate 9 out of 10
Rate 10 out of 10
If there were a way to whiten your teeth at a very reasonable investment would you be interested?
Yes
No
What is the most important thing to you about your future smile and dental health?
Previous
Next
Dental History
Are any of your teeth sensitive to:
Hot or cold?
Sweets?
Biting or Chewing?
Have you ever had:
Orthodontic treatment?
Oral Surgery?
Periodontal Treatment
Your teeth ground or bite adjusted?
A bite plate or mouth guard?
A serious injury to the mouth or head?
Have you noticed any mouth:
Odors or bad tastes?
Do you frequently get cold sores, blisters or oral lesions?
Do your gums bleed or hurt?
Have you noticed any loose teeth
Does food tend to become caught In between your teeth?
Yes
No
If Yes, Where?
Have you experienced:
Clicking or popping of the jaw?
Pain? (joint, ear, side of face)
Difficulty opening or closing mouth?
Difficulty chewing on either side?
Head, neck or shoulder pain?
Sore muscles? (neck/shoulders)
Are you satisfied with your teeth's appearance?
Do you feel nervous about dental treatment?
*
No
Yes
If so, what is your biggest concern?
Have you ever had an upsetting dental experience?
*
No
Yes
If so, please describe
Do You:
Clench or grind your teeth while awake or asleep?
Bite your lips or cheeks regularly?
Hold objects with your teeth? (pencils, pins, fingernails)
Mouth breathe while awake or asleep?
Have tired jaws, especially in the morning?
Snore/ sleeping disorders?
Smoke/ chew tobacco?
Have you ever needed to pre-medicate prior to dental treatment?
Is there anything else about having dental treatment that you would like us to know?
Yes
No
If yes, please describe
Previous
Next
Medical History Part 1
Please indicate which of the following you have had, or have at present:
AIDS/HIV
No
Yes
Kidney Disease
No
Yes
Alcohol Addiction
No
Yes
Liver Disease
No
Yes
Arthritis, Rheumatism
No
Yes
Low Blood Pressure
No
Yes
Anemia
No
Yes
Mitral Valve Prolapse
No
Yes
Artificial Heart Valves
No
Yes
Nervous Problems
No
Yes
Artificial Joints
No
Yes
Neurological Disorders
No
Yes
Asthma
No
Yes
Pacemaker
No
Yes
Back Problems
No
Yes
Psychiatric Care
No
Yes
Bleeding Abnormally with Extractions or Surgery
No
Yes
Radiation Treatment
No
Yes
Blood Disease
No
Yes
Recreational Drugs
No
Yes
Breast Augmentation
No
Yes
Respiratory Disease
No
Yes
Cancer
No
Yes
Smoke Cigarettes
No
Yes
Chemotherapy
No
Yes
Rheumatic Fever
No
Yes
Chemical Dependency
No
Yes
Scarlet Fever
No
Yes
Circulatory Problems
No
Yes
Shortness of Breath
No
Yes
Congenital Heart Lesions
No
Yes
Sinus Trouble
No
Yes
Cortisone Treatments
No
Yes
Skin Rash
No
Yes
Cough, persistent or bloody
No
Yes
Special Diet
No
Yes
Stroke
No
Yes
Diabetes
No
Yes
Emphysema
No
Yes
Swollen Feet or Ankles
No
Yes
Epilepsy
No
Yes
Swollen Neck Glands
No
Yes
Fainting/Dizziness
No
Yes
Smokeless Tobacco
No
Yes
Headaches
No
Yes
Tonsillitis
No
Yes
Heart Murmur
No
Yes
Tuberculosis
No
Yes
Heart (surgery, disease, attack)
No
Yes
Tumor/Growth on Neck
No
Yes
Hemophilia
No
Yes
Thyroid Problems
No
Yes
Hepatitis
No
Yes
Weight Loss Unexplained
No
Yes
Herpes/Cold Sores
No
Yes
Do you wear contact lenses?
No
Yes
High Blood Pressure
No
Yes
Do you take aspirin daily?
No
Yes
Jaundice
No
Yes
Blood Thinners
No
Yes
Do you currently have or have you had any disease, conditions, or problems not listed?
No
Yes
If Yes, Please List
Previous
Next
Medical History Part 2
Have you been under the care of a medical doctor during the past two years?
Yes
No
If yes, for what?
Physician’s Name
*
Phone Number
*
Have you ever taken bisphosphonates for osteoporosis such as Actonel, Fosomax, Boniva and Reclast?
Yes
No
Have you been a patient in the hospital during the past five years?
No
Yes
Do you use more than 2 pillows to sleep?
No
No
Have you lost or gained more than 10 pounds in the past year?
No
Yes
WOMEN
Are you pregnant or think you may be pregnant?
No
Yes
Months
Nursing?
No
Yes
Do you use birth control?
No
Yes
Medical History Part 3
Allergies
*
Aspirin
Barbiturates (Sleeping Pills)
Codeine
Lodine
Latex
Penicillin
Sulfa
Local anesthesia
OTHER
NO ALLERGIES
List any Medications you are currently taking, including regular doses of aspirin or over the counter herbal medicines and the correlation dosage:
*
Pharmacy Name
Phone Number
Medical History Part 4
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all the questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the dentist of any changes in my health or medication(s).
Patient/Guardian Signature
Clear Signature
Date
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Doctors Signature
Clear Signature
Date
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Previous
Next
PATIENT-DENTIST ARBITRATION AGREEMENT
Article I.
It is understood that any dispute as to dental malpractice, this, as to whether any dental services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, would be de-termined by submission to arbitration as provided by California Law, and not by a lawsuit, or resort to court process, except as California law provides for judicial review or arbitration proceedings. Both parties of this contract by entering into it, have given up their constitutional right to have any such dispute decided in a court of law before a jury, and in-stead are accepting the use of arbitration.
Treatment in this office is contingent upon both parties consenting to this Arbitration Agreement.
Article I.
A. Parties to the Agreement:
The term “patient” as used in this agreement includes the undersigned individual, his or her spouse, children (whether born or unborn), and heirs, assigns or personal representatives. The individual signing this Agreement signs it on behalf of the foregoing persons, and intends to bind each of them to arbitration to the full extent permitted by law. The term “doctor” as used in this agreement includes the undersigned doctor and his or her professional corporation or partnership, and any employees, agents, successors in interest, heirs and assigns of the foregoing individuals or enti-ties and independent contractors. The doctor signing this agreement signs it on behalf of all the foregoing individual and entities, and intends to bind each of them to arbitration to full extent permitted by law.
B. Treatment Covered:
Patient understands and agrees that any dispute of the sort descried in Article I between doctor and patient will be subject to compulsory, binding arbitration.
C. Coverage of Pre-Natal Claims (If Applicable):
Patient understands and agrees that, if doctor treats her during pregnancy, any dispute or sort descried in Article I as to dental treatment rendered to or affecting the unborn child will be subject to compulsory, binding arbitration.
Article III.
A. Informal Resolution of Disputes:
In the event patient feels that a problem has arisen in connection with the dental care rendered by doctor to patient, patient will promptly notify doctor so that doctor may have the opportunity to resolve the matter. Notice may be given orally or in writing, and shall stop the running or statute of limitations forninety (90) days.
B. Method of Initiating Arbitration:
If the dispute is not resolved by mutual Agreement within ninety (90) days, patient may initiate arbitration by notifying doctor to that affect. The arbitrator shall be selected by the chief administrator of JAMS ENDISPUTE. The arbitrator must be selected within twenty-one (21) days of the signature on the receipt for a letter sent certified mail return re-ceipt request demanding that a dispute submitted to arbitration. Following the selection of the arbitrator, arbitration must be held within thirty (30) days.
C. Applicable Law:
The arbitration shall be conducted pursuant the California Arbitration Act (C.C.P. 1280-1296). The Arbitrator shall, in addition, have authority to order such other discovery as he/she deemed appropriate for a full and fair hearing of the case. A determination on the merits shall be rendered in accordance with the law of the State of California, including the provisions of the Medical Injury Compensation Reform Act 1975 which shall apply to the same extent as if to dis-pute or pending before a Superior Court of the State of California.
The arbitrator shall not have the power to commit errors of law or legal reasoning, and the arbitrator’s decision may be vacated or corrected pursuant the California Code of Civil Procedure Sections 12806.2 or 12086.6 for any such error. The prevailing party shall be entitled to attorney fees.
Article IV.
A. Revocation:
If you are signing this agreement and then change your mind, the law permits you to revoke the Agreement providing you give your doctor written notice within thirty (30) days of signing that you want to withdraw from the Agreement. However, doctor and patient agree that any claim arising for dental services rendered prior to revocation shall be sub-jected to arbitration. Furthermore, doctor is not obligated to continue the doctor/patient relationship should you de-cide to withdraw from the agreement.
NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF DENTAL MALPRACTICE DECIDED BY MUTUAL ARBITRATION AND YOU ARE GIVING UP RIGHT TO JURY OR COURT TRIAL, SEE ARTICLE I OF THIS CON-TRACT.
Signature
*
Clear Signature
Date
*
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HIPPA AGEEMENT
Protecting Your Confidential Health Information is Important to Us
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.
Our Promise!
Dear Patient:
This is not a meant to alarm you! Quite the opposite! It is our desire to communicate to you that we are taking the new Federal (HIPAA-Health Insurance Portability and Accountability Act) laws written to protect the confidentiality of your health information seriously. We do not ever want you to delay treatment because you are afraid your personal health history might be unnecessarily made available to others outside of our office.
So what has changed? Why a privacy policy now? Very good questions!
The most significant variable that has motivated the Federal government to legally inforce the importance of the privacy of health information is the rapid evolution of computer technology and its use in healthcare. The government has appropriately sought to standardize and protect the privacy of the electronic exchange of your health information. This has challenged us to review not only how your health information is used within our computers but also with the internet, phone, faxes, copy, machines, and charts. We believe this has been important exercise for us because it has disciplined us to put in writing the policies and procedures we use to ensure the protection of your health information everywhere it is used.
We want you to know about these policies and procedures which we developed to make sure your health information will not be shared with anyone who does not require it. Our office is subject to State and Federal law regarding the confidentiality of our health information and in keeping with these laws, we want you to understand our procedures and your rights as our valuable patient.
We will use and communicate your HEALTH INFORMATION only for the purposes of providing your treatment, obtaining payment and conducing health care options. Your health information will not be used for other purposes unless we have asked for and been voluntarily given your written permission.
How your HEALTH INFORMATION may be used:
To Provide Treatment
We will use your HEALTH INFORMATION within our office to provide you with the best dental care possible. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between hygienist, dental assistant, dentist, and business staff. In addition, we may share your health information with physicians, referring dentist, clinical and dental laboratories, pharmacies or other health care personnel providing you treatment.
To Obtain Payment
We may include your health information with an invoice use to collect payment for treatment you received in our office. We may do this with insurance forms filed for you in the mail or sent electronically. We will be sure to only work with companies with similar commitment to the security of your health information.
To Conduct Health Care Operations
Your health information may be used during performance evaluation of our staff. Some of our best teaching opportunities use clinical situations experienced by patients receiving care at our office. As a result, health information may be included in training programs for students, interns, associates, and business and clinical employees. It is also possible that health information will be disclosed during audits by insurance companies or government appointed agencies as part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine processes of certification, licensing or credentialing activities.
In Patient Reminders
Because we believe regular care is very important to your oral and general health, we will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may be of interest to you or your family. These communications are an important part of our philosophy of partnering with our patients to be sure they receive the best preventive and restorative care modern dentistry can provide. They may include postcards, letters, telephone reminders, or electronic reminders such as email (unless you tell us that you do not want the receive these reminders.
Abuse or Neglect
We will notify government authorities if we believe a patient is the victim of abuse, neglect, or domestic violence. We will make this disclose only when we are compelled by our ethical judgment, when we believe we are specifically required or authorized by law or with the patient’s agreement.
Public Health and National Security
We may be required to disclose to Federal officials or military authorities health information necessary to complete an investi-gation related to public health or national security. Health infor-mation could be important when the government believes that the public safety could benefit when the information could lead to the control or prevention of an epidemic or the understanding of new side effects of a drug treatment or medical device.
For Law Enforcement
As permitted or required by State of Federal law, we may dis-close your health information to a law enforcement official for certain law enforcement purposes, including, under certain lim-ited circumstances, if you are a victim of a crime or in order to report crime.
Family, Friends and Caregivers
We may share your health information with those you tell us will be helping you with home hygiene, treatment, medications, or payment. We will be sure to ask your permission first, In the case of an emergency, where you are unable to tell us what you want we will use our very best judgement when sharing your health information only when it will be important to those participating in providing your care.
Authorization to Us or Disclose Health Information
Other than what is stated above or where Federal, State or Local law requires of us, we will not disclose your health information other than with your written authorization. You may revoke that authorization in writing at any time.
Patient Rights
This new law is careful to describe that you have the fallowing rights to your health information.
Restrictions
You have the right to request restrictions on certain uses and disclosures of your health information. Our office will make eve-ry effort to honor reasonable restriction preferences from our patients.
Confidential Communications
You have the right to request that we communicate with you in a certain way. You may request that we only communicate your health information privately with no other family members pre-sent or through mail communications that are sealed. We will make every effort to honor your reasonable requests for confi-dential communications.
Inspect and Copy Your Health Information
You have the right to read, review and copy your health information, including you complete chart, x-rays and billing records. If you would like a copy of your health information, please let us know. We may need to charge you a reasonable fee to duplicate and assemble your copy.
Amend Your Health Information
You have the right to ask us to update or modify your records if you believe your health information records are incorrect or incomplete. We will be happy to accommodate you as long as our office maintains this information. In order to standardize our process, please provide us with your request in writing and de-scribe your reason for the change.
Your request may be denied if the health information record in question was not created by our office, is not part of our records or if the records containing your health information are deter-mined to be accurate and complete.
Documentation of Health Information
You have the right to ask us for a description of how and where your health information was used by our office for any reason other than treatment, payment or health operations. Our docu-mentation procedures will enable us to provide information on health information usage form April 14, 2003 and forward. Please let us know in writing the time period for which you are interested. Thank you for limiting your request to no more than six years at a time. We may need to charge you a reasonable fee for your request.
Request a Paper Copy of this Notice
You have the right to obtain a copy of this Notice of Privacy Prac-tice directly from our office at any time. Stop by or give us a call and we will mail or email a copy to you.
We are required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of our Privacy Practices. We are required to practice the policies and procedures described in this notice but we do re-serve the right to change terms of our Notice. If we change our privacy practices we will be sure all our patients receive a copy of the revised Notice.
You have the right to express complaints to us or to the Secre-tary of Health and Human Services if you believed your privacy rights have been compromised. We encourage you to express any concerns you may have regarding the privacy of your infor-mation. Please let us know of your concerns or complaints in writing.
Patient Acknowledgment
Patient Name(s)
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Thank you very much for taking the time to review how we are carefully using your health information. If you have any ques-tions we want to hear from you. If not, we would appreciate very much you acknowledging your receipt of our policy by signing and returning this paper. We look forward to seeing you again soon!
Signature
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Clear Signature
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