*Title
Please select Dr. Mr. Mrs. Ms.

*Marital Status:
Please select Married Single Divorced

*Birthday: (mm/dd/yyyy)

*Last Name:    *First Name:

*Middle Initial:    Suffix: Please select Jr. Sr III IV

*Address:

APT:

*City:    *State:    *Zip Code:

*What is the best way to contact you?
Day Phone
Evening Phone
Mobile

*Enter Phone Number:

Fax:

*Email:

REFERRAL INFORMATION

*Referring/Present Dentist:

*Referred by:

*Work Phone:    Work Fax:

Your Work Secretary's Name:

How did you hear about us?
Please select one dentist patient relative internet other

If other, please list:

PHYSICIAN INFORMATION

*Physician's Name:

*Date of last visit: (mm/dd/yyyy)

*Physician's address

*Physician's phone #:

Do you have other physicians we need to know about?
If yes, please list:

*Do you, or have you had, any of the following? Check each appropriate box.
ALLERGIES TO DRUGS?
IF YES, TO WHAT?

ALLERGIES TO DENTAL ANESTHETICS:

DO YOU SMOKE
IF YES, HOW MUCH?

PRESENTLY PREGNANT
If yes, what month?

NONE
HEART AILMENTS
MITRAL VALVE PROLAPSE
HEART MURMUR
PACEMAKER
RHEUMATIC FEVER
HIGH/LOW BLOOD PRESSURE
ANEMIA/BLEEDING FROM CUTS or EXTS
STROKE
NEUROLOGICAL PROBLEMS
BISPHOSPHONATES (STRENGTHEN BONES)
SINUS PROBLEMS
ASTHMA
EYE DISORDERS
THYROID DISEASE
ARTHRITIS
DIABETES
ASPIRIN THERAPY
COUMADIN OR BLOOD THINNERS
KIDNEY DISEASE
LIVER DISEASE OR HEPATITIS
ULCER/COLITIS
MALIGNANCIES
ORTHOPEDIC PROSTHESIS (HIPS, KNEES,ETC.)
HIV POSITIVE
AIDS
TUBERCULOSIS
PSYCHIATRIC CARE
DO YOU TAKE BIRTH CONTROL PILLS
HORMONE REPLACMENT THERAPY

RADIATION TREATMENT

If yes:
Where (the portal)?

When: (mm/dd/yyyy)

Does your physician require you to pre-medicate with antibiotics for dental treatment?
Yes No

If yes, which antibiotic?
Please select one Amoxicillin Penicillin Zithromax Cipro Clindamycin Other

If other antibiotic, please list:

*Describe any medical treatment you are presently undergoing (if none, enter "None"):

*List all medications you are presently taking, including their dosages (if none, enter "None"):

Questions/Comments:

*Typing your full name in the textbox is your confirmation that the above information is accurate:    *Date: (mm/dd/yyyy)

Please answer all questions including the consent for use and disclosure of health information

DENTAL HISTORY

*Please Explain Your Chief Oral Complaint

Have you had a bleeding emergency from any dental treatment?
Yes No

If yes, please explain:

Date of last dental treatment/exam: (mm/dd/yyyy)

Is this visit for a second opinion? Yes No

Although we do not accept insurance assignment, our statements may be submitted for reimbursement.

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Please read the following statements carefully before signing this form

Purpose of consent: By signing this form, you consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to: Executive Administrator, Central Park Periodontics, P.C., 40 Central Park South, Ste 2E, NY, NY 10019. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

SIGNATURE

*Typing your full name in the textbox is your confirmation that the above information is accurate
I, ,
have received and had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare.

*I give my consent on this date: (mm/dd/yyyy)

If this Consent is signed by a personal representative on behalf of the patient, please complete the following:

Personal Representative's Name:

Relationship to Patient: