By submitting this form you realize that submissions may not be protected by the Health Insurance Portability and Accountability Act (HIPAA) and associated regulations. For HIPAA compliance please download the form and print it before coming into the office.
Your Name (required)
Your Email (required)
Date of Birth:
Address
Apt/Unit
City
Postal Code
Home Phone
Work
Cell
Email
Preferred Contact Method
Emergency Contact Person
Name of Policy Holder
Date of Birth
Group Policy/ Plan Number
I.D./Certificate Number
Employer
Name of Insurance Company
I, understand, certify that I (or my dependent) have insurance coverage and assign directly to Drs. Bishara-Margolian DPC all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize Drs. Bishara –Margolian to release all information necessar to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.
Authorized Signature:
* All fees or balances not covered by your dental insurance policy will be payable at time of visit. You must provide us with all insurance information. We do not have access to your private insurance policy information unless provided to us.
WebsiteInternetYellow PagesReferral
Family Member or Friend
Other
Sensitivity Grinding or clenching teethTooth Pain or Discomfort While ChewingBleeding, swollen or irritated gumsHeadaches, earaches, or neck painLoose or shifting teethJaw Joint Pain (clicking/cracking)Bad breath or taste in the mouthBroken Teeth or Fillings
When was your last dental visit
What was done at that visit
When having dental treatment do you require sedation
nitrous oxide (laughing gas)oral medication
Do you smoke or chew tobacco?
If “yes” for how long
AIDSDiabetesHigh Blood PressureRheumatic FeverAllergiesEmphysemaHIV PositiveSeizuresAnaemiaExcessive BleedingJaundiceSnoring/Sleep ApneaArthritisFaintingKidney DiseaseStomach ProblemsArtificial JointsGlaucomaLiver DiseaseStrokeAsthmaHeart ConditionsLow Blood PressureThyroid DiseaseBlood DisordersHeart MurmurPacemakerTuberculosisCancerHeart DiseasePregnant UlcersChemotherapyHepatitis A, B or CRespiratory ProblemsOther
AspirinCodeinePenicillinSulphaDrugsLocalAestheticLatex Other
Do you have any joint replacements?
Are you currently under a physician’s care?
For?
Physician’s Name and Phone Number Pharmacy’s Name and Phone Number
I certify that I have read, understood and accurately completed the personal, medical and dental histories to the best of my knowledge and have not knowingly omitted any information. If required, I consent to my physician being contacted regarding any specific medical questions. I authorize Drs. Bishara-Margolian and their staff to perform necessary diagnostic procedures and treatment as required to achieve a proper level of dental care.
Signature
Date
