"*" indicates required fields Step 1 of 4 25% Preferred Name* Today's Date* MM slash DD slash YYYY Patient Name* First Middle Last Date of Birth* MM slash DD slash YYYY Age* SSN* Marital Status* Mailing Address* Street Address City State / Province / Region ZIP / Postal Code Email Cell Phone*Home PhoneWork PhoneEmployer* Job Title How did you hear about our office?* Family Friend Online Whom may we thank for referring you?* Insurance InformationYou may skip this section if we have received your insurance information prior to appointmentSubscriber's Address (if different from above) Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Subscriber's Phone (cell)Alternate PhoneGroup # ID # Medical HistoryDo you now, or have you ever had any of the followingAIDS / HIV* Yes No Kidney Disease* Yes No Lupus* Yes No Mitral Valve Prolapse* Yes No Rheumatic Fever* Yes No Spleen Removal* Yes No Anemia* Yes No Arthritis* Yes No Artificial Joints/Implants* Yes No Asthma* Yes No Beta Blocker* Yes No Blood Disease* Yes No Blood Thinners* Yes No Breast Cancer* Yes No Cephalosporin Allergy* Yes No Crohn's Disease* Yes No Diabetes* Yes No Emphysema* Yes No Epilepsy* Yes No Erythromycin Allergy* Yes No Excessive Bleeding* Yes No Fainting* Yes No Glaucoma* Yes No Hay Fever* Yes No Head Injury* Yes No Heart Disease* Yes No Heart Attack / Angina* Yes No Heart Murmur* Yes No Hepatitis / Jaundice* Yes No High Blood Pressure* Yes No Latex Allergy* Yes No Liver Disease* Yes No Mental Disorders* Yes No Motrin Allergy* Yes No Nervous Disorders* Yes No Osteoporosis* Yes No Osteomalacia* Yes No Osteonecrosis of the jaw* Yes No Pacemaker* Yes No Paget's Disease* Yes No Penicillin Allergy* Yes No Radiation Treatment* Yes No Respiratory Issues* Yes No Rheumatism* Yes No Sinus Problems* Yes No Stroke* Yes No Sulfur Allergy* Yes No Tetracycline Allergy* Yes No Thrombocytopenia* Yes No Thyroid Problems* Yes No Tuberculosis* Yes No Tumors* Yes No Please record any conditions/disease not listedAre you currently under medical treatment?* Yes No If yes, please explain Do you use tobacco products?* Yes No Do you take Blood Thinners?* Yes No If yes, please list Please list your current prescriptions or provide a copy of your current list of medications:Please check if you are allergic or have had any reactions to the following:Aspirin* Yes No Penicillin* Yes No Latex* Yes No Local Anesthetics (i.e. Novocaine)* Yes No Codeine* Yes No Barbiturates* Yes No Sulpha Drug* Yes No Any metal (i.e. Nickel, Mercury, etc.)* Yes No Others* Yes No If others, please list* Do you take or have you taken any of the following medications or any other Bisphosphonate medications? Zometa* Yes No Aredia* Yes No Fosamax* Yes No Boniva* Yes No Actonel* Yes No Didronel* Yes No Skelid* Yes No Prolea* Yes No Women OnlyAre you pregnant or suspect that you may be pregnant? Yes No Are you nursing? Yes No AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATIONI hereby authorize Marc Berger Choice Dentistry to use or disclose my Protected Health Information as described below. I understand that the information I authorize a person/facility to receive may be re-disclosed and no longer protected by state and federal regulationsPatient's Name* First Last Today's Date* MM slash DD slash YYYY Name of Person(s) Authorized to RECEIVE the information* First Last I understand that by signing this Consent form, I am giving my consent to Marc Berger Choice Dentistry to disclose and discuss my protected health information to carry out treatment, payment activities and health car operations with the following family member.Name* First Last Relationship* 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 the Compliance Officer.Patient's Signature (Legal Guardian, if Patient is a minor)*Date* MM slash DD slash YYYY Information to be used/disclosed Complete Chart X-rays Clinical Notes Billing Summary Procedure Summaries FINANCIAL POLICYFull payment is due at the time services are rendered. In the event that a balance exists after an appointment, said balance must be paid within 30 days unless prior arrangements have been made. We realize that temporary financial problems may affect timely payment on an account. If such problems arise, it is the patient's responsibility to contact our billing department promptly for payment arrangements and assistance in management of the account. Any balance remaining after 60 days is subject to referral to collections agency. Patient/Guarantor will be responsible for any costs incurred if account is turned over to a collection agency, including collection fees, attorney fees, and any other associated court costs.Responsible PartyPerson responsible for payment if patient is minor/under the age of 18Your Name* First Last Relationship to Patient* Date of Birth* MM slash DD slash YYYY SSN* Mailing Address* Street Address Address Line 2 City State / Province / Region ZIP / Postal Code AfghanistanAlbaniaAlgeriaAmerican SamoaAndorraAngolaAnguillaAntarcticaAntigua and BarbudaArgentinaArmeniaArubaAustraliaAustriaAzerbaijanBahamasBahrainBangladeshBarbadosBelarusBelgiumBelizeBeninBermudaBhutanBoliviaBonaire, Sint Eustatius and SabaBosnia and HerzegovinaBotswanaBouvet IslandBrazilBritish Indian Ocean TerritoryBrunei DarussalamBulgariaBurkina FasoBurundiCabo VerdeCambodiaCameroonCanadaCayman IslandsCentral African RepublicChadChileChinaChristmas IslandCocos IslandsColombiaComorosCongoCongo, Democratic Republic of theCook IslandsCosta RicaCroatiaCubaCuraçaoCyprusCzechiaCôte d'IvoireDenmarkDjiboutiDominicaDominican RepublicEcuadorEgyptEl SalvadorEquatorial GuineaEritreaEstoniaEswatiniEthiopiaFalkland IslandsFaroe IslandsFijiFinlandFranceFrench GuianaFrench PolynesiaFrench Southern TerritoriesGabonGambiaGeorgiaGermanyGhanaGibraltarGreeceGreenlandGrenadaGuadeloupeGuamGuatemalaGuernseyGuineaGuinea-BissauGuyanaHaitiHeard Island and McDonald IslandsHoly SeeHondurasHong KongHungaryIcelandIndiaIndonesiaIranIraqIrelandIsle of ManIsraelItalyJamaicaJapanJerseyJordanKazakhstanKenyaKiribatiKorea, Democratic People's Republic ofKorea, Republic ofKuwaitKyrgyzstanLao People's Democratic RepublicLatviaLebanonLesothoLiberiaLibyaLiechtensteinLithuaniaLuxembourgMacaoMadagascarMalawiMalaysiaMaldivesMaliMaltaMarshall IslandsMartiniqueMauritaniaMauritiusMayotteMexicoMicronesiaMoldovaMonacoMongoliaMontenegroMontserratMoroccoMozambiqueMyanmarNamibiaNauruNepalNetherlandsNew CaledoniaNew ZealandNicaraguaNigerNigeriaNiueNorfolk IslandNorth MacedoniaNorthern Mariana IslandsNorwayOmanPakistanPalauPalestine, State ofPanamaPapua New GuineaParaguayPeruPhilippinesPitcairnPolandPortugalPuerto RicoQatarRomaniaRussian FederationRwandaRéunionSaint BarthélemySaint Helena, Ascension and Tristan da CunhaSaint Kitts and NevisSaint LuciaSaint MartinSaint Pierre and MiquelonSaint Vincent and the GrenadinesSamoaSan MarinoSao Tome and PrincipeSaudi ArabiaSenegalSerbiaSeychellesSierra LeoneSingaporeSint MaartenSlovakiaSloveniaSolomon IslandsSomaliaSouth AfricaSouth Georgia and the South Sandwich IslandsSouth SudanSpainSri LankaSudanSurinameSvalbard and Jan MayenSwedenSwitzerlandSyria Arab RepublicTaiwanTajikistanTanzania, the United Republic ofThailandTimor-LesteTogoTokelauTongaTrinidad and TobagoTunisiaTurkmenistanTurks and Caicos IslandsTuvaluTürkiyeUS Minor Outlying IslandsUgandaUkraineUnited Arab EmiratesUnited KingdomUnited StatesUruguayUzbekistanVanuatuVenezuelaViet NamVirgin Islands, BritishVirgin Islands, U.S.Wallis and FutunaWestern SaharaYemenZambiaZimbabweÅland Islands Country Email Home Phone*Cell Phone*Employer* Job Title* Work Phone*I have read, understand and agree to the Marc Berger Choice Dentistry Financial Policy.Patient/Guarantor's Signature*Date* MM slash DD slash YYYY Print Name* First Last ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATIONPURPOSE OF CONSENT: BY SIGNING THIS FORM YOU WILL CONSENT TO OUR USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION TO CARRY OUT TREATMENT, PAYMENT ACTIVITIES, AND HEALTH CARE 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 healthcare 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", 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 the contact person listed on this form. 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 revoke this consent. I have had full opportunity to read and consider the contents of the 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 health information to carry out treatment, payment activities and health care operations.Signature*Date* MM slash DD slash YYYY Relationship to Patient* YOU ARE ENTITLED TO A COPY OF THIS CONSENT ONCE SIGNED You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice at any time by contacting our office at: Telephone (803)888-2012 Fax: (803)888-4695 Email: julieberger@mbchoicedentistry.com Address: 928 Woodrow St, Columbia, SC, 29205FOR OFFICE USE ONLY: We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:
