Thank you for selecting our dental healthcare team!

We will strive to provide you with the best possible dental care.

To help us meet all your dental healthcare needs, please fill out this form.

If you have any questions or need assistance, please ask us!

PATIENT INFORMATION
Date

Name
Birth date
SS#/SIN
Patient #

Address
City
State
Zip

Email
Home Phone No.
Cell

Check Appropriate Box:
Minor Single Married Divorced Widowed Saparated

If Student, Name of School/College
City
State:
Full Time Part Time

Patient or Parent/Guardian's Employer
Work Phone:

Address
City
State
Zip

Spouse or Parent/Guardian's Name
Employer
Work Phone

Whom may we thank for referring you?

Person to contact in case of emergency
Phone

Responsible Party

Name of Person Responsible for this account
Relationship to Patient

Address
Home Phone

Email
Cell Phone

Driver's License #
Birth Date
Financial Institutaion

Employer
Work Phone
SS#/SIN

Is this person currently a patient in our office?
Yes No

For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.
Cash Personal Check Credit Card VISA Master Card I Wish to discuss the office's payment policy.

Insurance Information

Name of Insured
Relationship to Patient

Birth Date
SS#/SIN
Date Employed

Name of Employer
Union or Local #
Work Phone

Address of Employer
City
State
Zip

Insurance Company
Group #
Policy/ID #

Ins. Co. Address
City
State
Zip

How much is your deductible?
How much have you used?
Max. annual benefit

Do you have any additional insurance
Yes No
If Yes, Complete The Following

Name of Insured
Relationship to Patient

Birth Date
SS#/SIN
Date Employed

Name of Employer
Union or Local #
Work Phone

Address of Employer
City
State
Zip

Insurance Company
Group #
Policy/ID #

Ins. Co. Address
City
State
Zip

How much is your deductible?
How much have you used?
Max. annual benefit

Patient Medical History

Physician
Office Phone
Date of Last Exam

Yes No

1. Are you under medical treatment now?
2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?

If yes, please explain

3. Are you taking any medication(s) including non-prescription medicine?

If yes, what medication(s) are you taking?

4. Have you ever taken Fen-Phen/Redux?

5. Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates?

6. Have you taken Viagra, Revatio, Cialis or Levitra in the last 24 hours?

7. Do you use tobacco?

8. Do you use controlled substances?

Yes No

10. Are you wearing contact lenses?

11. Are you allergic to or have you had any reactions to the following?

Local Anesthetics (e.g. Novocain)

Penicillin or any other Antibiotics

Sulfa Drugs

Barbiturates

Sedatives

Iodine

Aspirin

Any Metals (e.g. nickel, mercury, etc.)

Latex Rubber

Other (please list)

12. Do you have persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

13. Women Only:

a) Are you pregnant or think you may be pregnant?

b) Are you nursing?

c) Are you taking oral contraceptives?

9. Do you have or have you had any of the following?

Yes No

High Blood Pressure

Heart Attack

Rheumatic Fever

Swollen Ankles

Fainting/Seizure

Asthma

Low Blood Pressure

Epilepsy/Convulsions

Leukaemia

Diabetes

Kidney Diseases

AIDS or HIV Infection

Thyroid Problem

Heart Disease

Cardiac Pacemaker

Heart Murmur

Angina

Frequently Tired

Anemia

Emphysema

Cancer

Arthritis

Joint Replacement or Implant

Hepatitis/Jaundice

Sexually Transmitted Disease

Stomach Troubles/Ulcers

Chest Pains

Easily Winded

Stroke

Hay Fever/Allergies

Tuberculosis

Radiation Therapy

Glaucoma

Recent Weight Loss

Liver Disease

Heart Trouble

Respiratory Problems

Mitral Valve Prolapse

Name of Previous Dentist and Location
Date of Last Exam

Yes No

1. Do your gums bleed while brushing or flossing?

2. Are your teeth sensitive to hot or cold liquids/foods?

3. Are your teeth sensitive to sweet or sour liquids/foods?

4. Do you feel pain to any of your teeth?

5. Do you have any sores or limps in or near your mouth?

6. Have you had any head, neck or jaw injuries?

7. Have you ever experienced any of the following problems in your jaw?

Clicking

Pain (joint, ear, side of face)

Difficulty in opening or closing

Difficulty in chewing

Yes No

8. Do you frequent headaches?

9. Do you clench or grind your teeth?

10. Do you bite your lips or cheeks frequently?

11. Have you ever had any difficult extractions in the past?

12. Have you ever had any prolonged bleeding following extractions?

13. Have you had any orthodontic treatment?

14. Do you wear dentures or partials?

If yes, date of placement

15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

16. Do you like your smile?

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors 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 services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

Signature of patient (or parent/guardian if minor)
Date

Quincy Dental Care, PC

HIPAA NOTICE OF PRVACY PRACTICES

("Notice")

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.

The Dental Practice Covered By This Notice

This Notice describes the privacy practices of Quincy Dental Care, PC. ("Dental Practice"). "We" and "our" means the Dental Practice. "You" and "your" means our patient.

How to Contact Us/Our Privacy Official

If you have any questions or would like further information about this Notice, you can either write or call the Privacy Official for our Dental Practice:

Dental Practice Name: Quincy Dental Care, PC

Privacy Official for Dental Practice: Dr. Marianella Romero

Dental Practice mailing address: 1261 FURNACE BROOK PARKWAY, SUITE 28 QUINCY, MA 02169

Dental Practice email address: qdcoffice.info@gmail.com

Dental Practice phone number: 617-471-8355

Information Covered By This Notice

This Notice applies to health information about you that we create or receive and that identifies you. This Notice tells you about the ways we may use and disclose your health information. It also describes your rights and certain obligations we have with respect to your health information. We are required by law to:

• Maintain the privacy of your health information;

• Give you this Notice of our legal duties and privacy practices with respect to that information; and

• Abide by the terms of our Notice that is currently in effect.

Our Use and Disclose of Your Health Information Without Your Written Authorization

Common Reasons for Our Use and Disclosure of Patient Health Information

Treatment. We will use your health information to provide you with dental treatment or services, such as cleaning or examining your teeth or performing dental procedures. We may disclose health information about you to dental specialists, physicians, or other health care professionals involved in your care.

Payment. We may use and disclose your health information to obtain payment from health plans and insurers for the care that we provide to you.

Health Care Operations. We may use and disclose health information about you in connection with health care operations necessary to run our practice, including review of our treatment and services, training, evaluating the performance of our staff and health care professionals, quality assurance financial or billing audits, legal matters, and business planning and development

Appointment Reminders. We may use or disclose your health information about you when contacting you to remind you of a dental appointment. We may contact you by using a postcard, letter, voicemail, or email.

Treatment Alternatives and Health-Related Benefits and Services. We may use and disclose your health information to tell you about treatment options or alternatives or health-related benefits and services that may be of interest to you.

Disclosure to Family Members and Friends. We may disclose your health information to a family member or friend who is involved with your care or payment for your care if you do not object or, if you are not present, we believe it is in your best interest to do so.

Less Common Reasons for Use and Disclosure of Patient Health Information

The following uses and disclosures occur infrequently and may never apply to you.

Disclosures Required by Law. We may use or disclose patient health information to the extent we are required by law to do so. For example, we are required to disclose patient health information to the U.S. Department of Health and Human Services so that it can investigate complaints or determine our compliance with HIPAA.

Public Health Activities. We may disclose patient health information for public health information for public health activities and purposes, which include: preventing or controlling disease, injury or disability reporting births or deaths; reporting child abuse or neglect; reporting adverse reactions to medications or foods; reporting product defects; enabling product recalls; and notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition.

Victims of Abuse, Neglect or Domestic Violence. We may disclose health information to the appropriate government authority about a patient whom we believe is a victim of abuse, neglect or domestic violence.

Health Oversight Activities. We may disclose patient health information to a health oversight agency for activities necessary for the government to provide appropriate oversight of the health care system, certain government benefit programs and compliance with certain civil rights laws.

Lawsuits and Legal Actions. We may disclose patient health information in response to (i) a court or administrative order or (ii) a subpoena, discovery request, or other lawful process that is not ordered by a court if efforts have been made to notify the patient or to obtain an order protecting the information requested.

Law Enforcement Purposes. We may disclose patient health information to a law enforcement official for a law enforcement purposes, such as to identify or locate a suspect, material witness or missing person or to alert law enforcement of a crime.

Coroners, Medical Examiners and Funeral Directors. We may disclose patient health information to a coroner, medical examiner or funeral director to allow them to carry out their duties.

Organ, Eye and Tissue Donation. We may use or disclose patient health information to organ procurement organizations or others that obtain, bank or transplant cadaveric organs, eyes or tissue for donation and transplant.

Research Purposes. We may use or disclose patient health information for research purposes pursuant to patient authorization waiver approval by an Institutional Review Board or Privacy Board.

Serious Threat to Health or Safety. We may use or disclose patient health information if we believe it is necessary to do so to prevent or lessen a serious threat to anyone's health or safety.

Specialized Government Functions. We may disclose patient health information to the military (domestic or foreign) about its members or veterans, for national security and protective services for the President or other heads of state, to the government for security clearance reviews. And to a jail or prison about its inmates.

Workers Compensation. We may disclose patient health information to comply with workers' compensation laws or similar programs that provide benefits for work-related injuries or illness.

Your Written Authorization for Any Other Use or Disclosure of Your Health Information

We will make other uses and disclosures of health information not discussed in this Notice only with your written authorization. You may revoke that authorization at any time in writing. Upon receipt of the written revocation, we will stop using or disclosing your health information for the reasons covered by the authorization going forward.

Your Rights with Respect to Your Health Information.

You have the following rights with respect to certain health information that we have about you (information in a Designated Record Set as defined by HIPAA). To exercise any of these rights, you must submit a written request to our Privacy Official listed on the first page of this Notice.

Access. You may request to review or request a copy of your health information. We may deny your request under certain circumstances. You will receive written notice of a denial and can appeal it. We will provide a copy of your health information in a format you request if it is readily producible. If not readily producible, we will provide it in a hard copy format or other format that is mutually agreeable. If your health information is included in an Electronic Health Record, you have the right to obtain a copy of it in an electronic format and to direct us to send it to the person or entity you designate in an electronic format. We may charge a reasonable fee to cover our cost to provide you with copies of your health information.

Amend. If you believe that your health information is incorrect or incomplete, you may request that we amend it. We may deny your request under certain circumstances. You will receive health information you believe is incorrect or incomplete.

Restrict Use and Disclosure. You may request that we restrict uses of your health information to carry out treatment, payment, or health care operations or to your family member or friend involved in your care or the payment for your care. We may not (and are not required to) agree to your requested restrictions, with one exception. If you pay out of your pocket in full for a service you receive from us and you request that we not submit the claim for this service to your health insurer or health plan for reimbursement, we must honor that request.

Confidential Communications: Alternative Means, Alternative Locations. You may request to receive communications of health information by alternative means or at an alternative location. We will accommodate a request if it is reasonable and you indicate that communication by regular means could endanger you. When you submit a written request to the Privacy Official listed on the first page of this Notice, you need to provide an alternative method of contactor alternative method of contact or alternative address and indicate how payment for services will be handled

Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information for the six years prior to the date that the accounting is requested except for disclosures to carry out treatment, payment, health care operations (and certain other exceptions as provided by HIPAA). The first accounting we provide in any 12-month period will be without charge to you. We will charge a reasonable fee to cover the cost for each subsequent request for an accounting within the same 12-month period. We will notify you in advance of this fee and you may choose to modify or withdraw your request at that time.

Receive a Paper Copy of this Notice. You may have the right to a paper copy of this Notice. You may ask us to give you a paper copy of the Notice at any time (even if you have agreed to receive the Notice electronically). To obtain a paper copy, ask the Privacy Official.

We Have the Right to Change Our Privacy Practices and This Notice

We reserve the right to change the terms of this Notice at any time. Any change will apply to the health information we have about you or create or receive in the future. We will promptly revise the Notice when there is a material change to the uses or disclosures, individual's rights, our legal duties, or other privacy practices discussed in this Notice. We will post the revised Notice on our website (if applicable) and in our office and will provide a copy of it to you on request. The effective date of this Notice (including any updates) is in the top right-hand corner of the Notice.

To Make Privacy Complaints

If you have any complaints about your privacy rights or how your health information has been used or disclosed, you may file a complaint with us by contacting our Privacy Official listed on the first page of this Notice.

You may also file a written complaint with the U.S. Department of Health and Human Services Office for Civil Rights.

The privacy of your health information is important to us. We will not retaliate against you in any way if you choose to file a complaint.

Quincy Dental Care, PC

ACKNOWLEDGEMENT OF RECEIPT OF

HIPAA NOTICE OF PRVACY PRACTICES

("Acknowledgement")

I acknowledge that I have received a copy of this Dental Practice's HIPAA Notice of Privacy Practices.

Patient Name

Patient Signature
Date

Signature of Personal Representative

Authority of Personal Representative to Sign for Patient (Check One)

Guardian Parent Power of Attorney Other

Please Note: It is your right to refuse to sign this Acknowledgement

Dental Office Use Only

I tried to obtain written Acknowledgement by the individual noted above of receipt of our Notice of Privacy Practices, but it could not be obtained because:

___ An emergency prevented us from obtaining acknowledgement.

___ A communication barrier prevented us from obtaining acknowledgement.

___ The individual was unwilling to sign.

___ Other________________________________________________________________________________

________________________________________
________________________________________

Staff Member Signature
Date