PATIENT INFORMATION Please take a moment to enter or update your information to help the ensure the quality of your care is excellent Patient name * First Name Last Name Title Mr Ms Mrs Gender * Male Female Family Status Married Single Child Other Birth Date * MM DD YYYY Prev. Visit MM DD YYYY Phone Home * (###) ### #### Mobile (###) ### #### Work (###) ### #### Ext work phone Address Address 1 Address 2 City State/Province Zip/Postal Code Country Email * Preferred appointment times * Mon Tue Wed Thur Fri Whom may we thank for referring you to our practice? None Dental Office Yellow Pages Internet Facebook Instagram School Work Other (name bellow) Name or person, office, or other source referring you to our practice Spouse or Responsible Party information This following is for: The patient spouse the person responsible for payment both neither-not applicable Name First Name Last Name Title mr Ms Mrs Family status Married Single Child Other Gender Male Female Birth Date MM DD YYYY Email Address Phone home (###) ### #### Mobile (###) ### #### Phone work (###) ### #### Ext. phone work Best time to call Address Address 1 Address 2 City State/Province Zip/Postal Code Country CONSENT FOR SERVICES As a condition of treatment by this office, financial arrangements must be made in advance.. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment. All emergency dental services , or any dental service performed without previous financial arrangements , must be paid for in cash at the time services are performed unless other arrangements are made. Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient's insurance forms or assist in making collections from insurance companies and will credit any collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company A service charge 1½ % per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangement are satisfied. I understand that any fee estimate for this dental care can only be extended for a period of six month from the date of the patient examination. In consideration for the professional services rendered to me by this practice , i agree to pay the charges for the services at the time of treatment, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and i further agree to pay all cost and reasonable attorney fees if suit be instituted hereunder. I grant my permission to you or your assignee, to telephone me to discuss this statement or my treatment. I have read the above conditions of treatment and payment and agree to their content. * YES Patient, parent, or guardian (responsible party): First Name Last Name Relationship to Patient: MEDICAL HISTORY By checking the box it will indicate a "Yes" response, leaving blank indicate a "No" response. *Pre med - Amox *Pre med - Other Allergy - Erythro Allergy - Penicillin Allergy - Iodine Arthritis Cancer Excessive Bleeding Heart Disease HIV Mental Disorders Pacemaker Respiratory Problems Stomach Problems Allergies Allergy- Hay Fever Allergy - Sulfa Allergy - Tetracycline Artificial Joints Diabetes Fainting Heart Murmur Jaundice Mitral Valve Prolaps Pregnancy Rheumatic Fever Stroke Venereal Disease Allergy - Aspirin Allergy - Latex Allergy - Bioxin Allergy - Tylenol Asthma Dizziness Glaucoma Hepatitis Kidney Disease Nervous Disorders Pt takes Comadin Rheumatism Tuberculosis Allergy - Codeine Allergy - Other Allergy - Cortizone Anemia Blood Disease Epilepsy Head Injuries High Blood Pressure Liver Disease Other Radiation Treatment Sinus Problems Tumors Are you Pregnant? Yes No Are you a Smoker? Yes No Are you taking Blood thinners? Yes No Do you suffer from frequent headaches? Yes No DENTAL INFORMATION How do you rate the condition of your mouth? Excellent Good Fair Poor Date of most recent dental exam MM DD YYYY I routinely see my dentist every: 3mo 4mo 6mo 12mo Not routinely What is your immediate concern? IN CASE OF EMERGENCY Name of local friend ( not living at same address) First Name Last Name Relationship to patient Home phone # (###) ### #### Work phone # (###) ### #### The above information is true to the best of my knowledge I authorize my insurance benefits be paid directly to the physician . I understand that I am financially responsible for any balance. I also authorize [Name of Practice] or insurance company to release any information required processing my claims. Yes No Date MM DD YYYY Patient/Guardian Name First Name Last Name ASSIGMENT AND RELEASE I, the undersigned, have insurance with Name of the insurance Company (is) and assign directly tp Dr. Valiente all benefits, if any otherwise payable to me for service rendered. I understand that I am financially responsible for all charges whether or not paid by my insurance. I herby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic PHOTO CONSENT AND RELEASE FORM I, understand, do agree to the following. I am allowing Dr. Aladino Valiente D,M,D. or a staff member to take photos or videos of my treatment and/or treated areas for the purpose os monitoring my progress, education and/or advertising YES Patient Name First Name Last Name Date MM DD YYYY At my request, my identity will remain anonymous Please initials: PaATIENT RECEIPT OF PRIVACE PRACTICES AND CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION I have the right to review the notice of privacy practices prior to signing this consent. I have been given the opportunity to read and receive a copy of Aladino Valiente, D.M.D. , P.A. notice of privacy practices. Whit my consent Aladino Valiente, D.M.D. , P.A. may use and disclose protected health information about me to carry out treatment, payment and health care operations (TPO) Please refer to Aladino Valiente D.M.D. , P.A. Notice of Privacy Practice for a more complete description of such use and disclosures. Aladino Valiente D.M.D. ,P.A. reserve the right to revise its Notices Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Privacy Oficcer at Aladino Valiente D.M.D , P.A. 12781 sw 42 st suit D Miami FL 33179 (305) 226 7404 . Whit my consent Aladino Valiente D.M.D. , P.A. may call me home designated location and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others. Whit my consent Aladino Valiente D.M.D. , P.A. may mail to home or other designated location any items that assist the practice in carrying out TPO such as appointment reminder cards and patient statements as long are they are marked Personal and Confidencial. Whit my consent, Aladino Valiente D.MD. , P.A. may e-mail to may home or other designated any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. iI have the right to request that Aladino Valiente D.M.D. , P.A. restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement. By agree to this form, I am consenting to Aladino Valiente D.M.D , P.A. use and disclosure of my PHI to carry out TPO. I may revoke my consent in writing except to the extent to that the practice has already made disclosures in reliance upon my prior consent. If i do not agree to this consent, Aladino Valiente D.M.D , P.A. may decline to provide treatment to me * I agree Patient Name or guardian First Name Last Name Patient Name First Name Last Name Date MM DD YYYY OFFICE GUIDELINES SERVICE CHARGE: I understand that payment is due the day that services are rendered, I also understand that if have a Dental insurance and my insurance company decides to pay less I will be responsible to pay the difference. CANCELLATION FEE: We reserve the rights to charge a $30.00 cancellation fee for any appoint broken or cancelled without 24-hour notice. I have fully read and understand the customary guidelines written on this form. I agree Patient Name First Name Last Name Date MM DD YYYY CONSENT FOR INTERNET COMUNICATIONS Patient Name First Name Last Name I grant my permission to the dental practice to upload and store confidential patient information ( including account information, appoint information and clinical information) to the secure web site for the dental practice. I understand that. For security purpose. The site requires a user ID and password for access and use. I also understand the dental practice and i am responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any changes, damages, or losses that may by incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID nd password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns I also understand that the State and Federal Laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent any warrant that they will, at all times during the terms of this agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage go my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload, and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand that the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is upload to the web site on my behalf. I understand the dental practice CANNOT AND DOEAS NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES. I have read the information above regarding the secured uploading of patient information to the web site for dental practice, and grant the dental practice permission to securely upload my patient information to the web site Patent Name, Parent, or Guardian First Name Last Name Relationship to patient: Thank you!
