New Patient Information

Thank you for choosing the Dental Implant Institute. Prior to your dental appointment, please answer the questions below.

If you do not answer a Yes/No question, then your answer is a "NO" by default.

Patient Contact Information

Today's Date * +

Patient First Name *

Patient Last Name *

Age

Birth Date * +

Social Security Number

Gender *

Race

Ethnicity

Street Address *

Address Line 2

City *

State *

Zip Code *

Phone Number *

Email Address *

Verify email *

Marital Status

Employer Name *

Employer Address *

Employer Phone *

Emergency Contact Information

Emergency Contact Name *

Emergency Contact Phone *

Relation to Patient *

Patient Insurance Information

Primary Insurance Company

0/255 characters

Insured Full Name

0/255 characters

Insurance Phone Number

0/255 characters

Relation to Insured

0/255 characters

Group Number

0/255 characters

Insurance ID Number

0/255 characters

DOB of Insured +

Secondary Insurance

Secondary Insurance Company

0/255 characters

Secondary Insured Full Name

0/255 characters

Secondary Insurance Phone Number

0/255 characters

Secondary Relation to Insured

0/255 characters

Secondary Group Number

0/255 characters

Secondary Insurance ID Number

0/255 characters

Secondary DOB of Insured +

By selecting "Yes", you hereby authorize the assignment of your insurance rights and benefits directly to the provider for services rendered and that you fully understand that you are responsible for any balance not paid by your insurance company. *

Medical History

Do you have a personal physician? If yes, please list the name and contact information below:

Your current physical health condition is:

Are you currently under the care of a physician? If yes please explain below

Are you taking any prescription, over-the-counter drugs or supplements? If yes, please list prescriptions, over-the-counter-drugs or supplements you are taking:

Do you smoke or use tobacco in any form? *

For Women

Are you taking birth control pills?

Are you nursing?

Are you pregnant? If yes, please list how far along you are:

Reason(s) for seeing the dentist today

Why have you come to see the dentist today?

Do you require antibiotics before dental treatment?

Do you like your smile? If no, why?

Type of tooth brush bristles.

Do your gums ever bleed?

How many times a day do you brush?

How many times a week do you floss?

Have you ever had a serious or difficult problem with any previous dental work? If yes, please explain.

Have you ever experienced pain or discomfort in your lower jaw joint (TMJ/TMD)?

Have you ever taken Phen-Fen? (AKA Redux or Pondimin)

Diseases or Medical Problems

Heart and Circulatory Problems

Please select all the problems that apply.

Heart Attack

High Blood Pressure

Chest Pain (Angina)

Heart Murmurs

Artifical Valves

Other Heart Problems, if checked please comment Other Heart Problems, if checked please comment

Breathing/Lung Problems

Stomach Problems

Stomach Pain

History of Ulcers / Colitis

Mental Health Problems

Depression / Anxiety / History of Psychiatric Medications or Other Illness. If yes, please explain

Muscle and Bone Problems

Joint / Back Pain

Artificial valve, hip, knee or joint replacement

History of Broken Bones / Joint Swelling / Arthritis

Liver Problems

Hepatitis A, B or C

Alcoholic / Jaundice / Other Liver Disease

Neurologic Problems

Chronic Headaches / History of Head Injury / Numbness of Arms, Legs, Hands or Feet

Epilepsy / Seizures

History of Stroke

Blood Problems

Allergies

H.l.P.A.A. NOTICE OF PRIVACY PRACTICES

This notice describes how medical information about you may be used and disclosed and how you can get access to this information.

Please review it carefully.

This Notice of Privacy Practices describes how we may use and disclose your "Protected Health Information" (PHI) to carry out Treatment, Payment or Healthcare Operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. "Protected Health Information" (PHI) is information about you, including demographic information, that may identify you and that relates to your past, present or future physical or mental health or condition and related health care services.

Uses and Disclosures of Protected Health Information

Your protected health information (PHI) may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physician's practice, and any other use required by law.

TREATMENT - We will use and disclose your PHI to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, we would disclose PHI as necessary to a home health agency that provides care to you. For example, your PHI may be provided to a physician to whom you have been referred to ensure that the physician has the necessary information to diagnose or treat you.

PAYMENT - Your PHI will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for a hospital stay may require that your relevant protected health information be disclosed to the health plan to obtain approval for the hospital admission.

HEALTH CARE OPERATIONS - We may use or disclose as needed, your PHI in order to support the business activities of your physician's practice. These activities include but are not limited to, quality assessment activities, employee review activities, training of dental students, licensing, marketing, and fundraising activities, and conducting or arranging for other business activities. For example, we may disclose your PHI to dental school students that see patients in our office. In addition, we may utilize a sign-in sheet at the registration desk where you will be asked to sign your name and indicate your physician. We may also ca ll you by name in the waiting room when your physician is ready to see you. We may use or disclose your PHI as necessary to contact you to remind you of our appointment. We may use or disclose your PHI in the following sit uations without your authorization. These situations include public health issues as required by law, communicable diseases, health oversight, abuse or neglect, Food and Drug administration requirements, legal proceedings, law enforcement, coroners, funeral directors, and organ donation, research, criminal activity, national security, worker's compensation, inmates, required uses and disclosures, under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other permitted and required uses and disclosures will be made only with your consent, authorization or opportunity to object unless required by law. You may revoke thi s authorization at any time in writing, except to the extent that your physician or the physician's practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights - The following is a statement of your rights with respect to your PHI.

*You have the right to inspect and copy your PHI. Under federal law, however, you may not inspect or copy the following records: psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and PHI that is subject to law that prohibits access to protected PHI.

*You have the right to request a restriction of your PHI. This means that you may ask us not to disclose any part of your PHI for the purposes of treatment, payment or healthcare operations. You may also request that any part of your PHI not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

*Your physician is not required to agree to a restriction that you may request. If a physician believes it is in your best interest to permit use and disclosure of your PHI, your PHI will not be restricted. You then have the right to use another Healthcare professional.

*You have the right to request and receive confidential communications from us by alternative means or at an alternative location.

*You have the right to obtain a copy of this notice from us upon request, even if you have agreed to accept this notice alternatively, I.E. electronically.

*You may have the right to have your physician amend to your PHI. If we deny your request for amendment, you then have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and we will provide you with a copy of any such rebuttal.

*You have the right to change the terms of this notice and we will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints

You may complain to us or the Secretary of Health and Human Services if you believe you privacy rights have been violated by us. You may file a complaint with us or by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint.

If you have any comments regarding this notice please contact our office.

RECEIPT OF ACKNOWLEDGEMENT

We are required by law to maintain the privacy of and provide individuals with this notice of our legal duties and privacy practices with respect to Protected Health Information. *

I disagree with your HIPAA Privacy Practices

H.I.P.A.A SIGNATURE *

clear

GENERAL CONSENT

What you are being asked to sign is your acknowledgement that you have been informed and advised fully regarding the treatment of your condition and that the known risks of your treatment have been explained by the doctors and staff of the Dental Implant Institute (hereinafter "Dii"}. By signing this Consent you hereby affirm that you have asked Dr. Chen and/or Dr. Cha and/or Dr. Patterson and/or Dr. Greenwood about the frequency of any risks or complications disclosed herein that might apply to you based on our clinical experience and that you are satisfied that with the disclosures that have been provided. By signing this form you are also affirming that you consent and agree to treatment despite the known risks that were explained to me.

I understand the recommended treatment, the fees/costs associated with the same and the time involved in treating my condition.
I also understand that during the course of treatment, unforeseen conditions and/or complications may arise that could necessitate an extension or alteration from the contemplated treatment plan. These additional treatments may include, in addition to other things, root canal therapy, root amputation, extractions, sinus involvement including but not limited to sinus elevation and sinus membrane repair, or additional complex restorative therapy. I understand that such additional treatment(s) may result in additional charges which I agree to pay.
I understand that there are inherent and potential risks involved in any treatment, and in my case the risks include, but are not limited to: (a) Transient numbness of the lips, tongue, tooth, chin or gum when local anesthetics wear off. Time usually resolves this issue. If prolonged numbness occurs. please inform us. (b) Transient increased tooth sensitivity to hot, cold, sweet or acidic foods. This sensitivity usually subsides with time and can be helped through the use of special toothpaste for sensitive teeth. Please inform us of painful sensitivity. (c) Tenderness and stiffness within the chewing muscles or neck area, and difficulty opening your mouth or speaking. This is best treated with moist heat, a soft diet and over the counter analgesics (pain medication). (d) Soreness of the lips and cheeks caused by stretching of the mouth during instrumentation with possible minor abrasions. These will usually heal very rapidly without complications.
I understand that the fee I am to be charged for my treatment has been disclosed
to me, is satisfactory to me and includes no additional x-rays, injections or anesthetics that may later be necessary to correct any unforeseen complications which might warrant additional fees which I agree to pay. I understand that as a courtesy to me, the Dll office staff will assist in the preparation and filing of necessary insurance claims should I be insured. However, I further understand that the agreement of the insurance company to pay for medical expenses is a contract between myself and the insurance company and in no way alleviates my responsibility to pay for the medical services provided. I understand that some and perhaps maybe all of the services provided may not be covered or not considered reasonable and customary by my insurance company. I understand that I am responsible for paying all co-pays and deductibles at the time services are rendered and that any and all costs not paid for by my insurance within 45 days will become my responsibility. All accounts not paid in full within 90 days shall accrue interest at the rate of 18% per annum. I understand that I will be fully liable for all collection costs, including court costs and attorney fees should I fail to make any timely payment in full.
I understand that the fee I am to be charged for my proposed treatment includes payment of a non-refundable deposit. The amount of this deposit covers the costs of formulating an entire course of treatment designed to treat my specific condition as well as a discount applied by Dll for multiple procedures. In the event I cease or otherwise terminate treatment prior to completion of all procedures included in my treatment plan, then I will forfeit the entire amount of the non-refundable deposit. In addition to forfeiture of the non-refundable deposit upon early cessation of treatment, I will remain liable to Dll for all unpaid balances in connection with all procedures performed by Dr. Chen and/or Dr. Cha and their associates. Otherwise, upon completion of the final procedure of my treatment plan, the non-refundable deposit shall be applied as a credit to the final payment amount.
I agree to cooperate fully with the recommendations of Dr. Chen and/or Dr. Cha
and their associates while under his/her/their care understanding that the longterm success of my treatment depends on personal oral hygiene, completion of recommended dental therapy, regular follow-up care appointments and overall general health. In addition, I understand it is my responsibility to see the doctor at least twice a year for oral hygiene maintenance.
Dr. Chen and/or Dr. Cha and their associates will make every commercially reasonable effort to match the color, shape and size of my new crown(s) to my natural teeth or other visible dental work. I understand that slight color variations may occur and that more than one attempt may be necessary to obtain the proper crown color. I further understand that the final decision as to the proper crown color, and number of attempts to achieve the proper crown color, shall remain solely within the professional judgment and discretion of Dr. Chen and/or Dr. Cha and their associates.
I understand that a pre-existing condition of which I may or may not be aware that I have, may manifest itself or become aggravated during or after the dental treatment. I understand that Dr. Chen and/or Dr. Cha and their associates will not be responsible for the treatment of any such pre-existing condition(s) and that they will not be liable for any aggravation and/or exacerbation of any such preexisting condition(s), whether known or unknown including but not limited to
temporal mandibular disorder.
I understand no guarantee has been given to me that the proposed treatment will be curative and/or successful to my complete satisfaction, despite the fact that every effort will be made in the best professional judgment of the doctors to give me a proper diagnosis, treatment plan, restorative plan and prognosis.
I hereby authorize Dll to make an audio and/or video recording of my procedure(s) with my full and complete awareness to be used by DII for any purpose related to dentistry or my insurance, including, but not limited to payment/reimbursement from my insurance company, my on-going treatment
with Dll and/or teaching/instructional purposes for other physicians and/or patients. I hereby waive any and all claims against DII related to this Consent and hereby agree to indemnify and hold DII harmless from any and all such claims whether brought or alleged by myself or any third party. I also understand that the recording will not be used for any public broadcasting whatsoever (other than what is stated herein) and that copies, duplication's or the like of any such recording will not be provided to any third party - not associated or affiliated with Dll - without my prior written consent. I further acknowledge that I have asked any and all questions regarding this Consent and that I have signed this Consent voluntarily without any reliance on any promise or inducement not specifically stated herein.
I understand that other work has/may have been performed on my mouth by doctors other than Dll and/or currently is being performed by doctors other than Dll, and in no way will I hold DII liable for any work not performed by Dll.
I understand that if I turn down the Doctors' recommendation for an implant and instead choose to have Dll place a crown or bridge, then Dll makes no claims or guarantees regarding the success or longevity of the crown or bridge in this circumstance. If I choose the natural teeth bridge option instead of Dii's recommended implant option, then the modification of the bridge tooth/teeth site was my decision exclusively and DII is not responsible for any complications to the tooth/teeth site.

I hereby certify that I have read this form in its entirety and have had all my questions answered by my doctor regarding this form. I certify that I understand English and fully understand the terms and words within the above paragraphs. My signature below signifies that I understand the treatment plan that is proposed to me together with its known risks and complications and that I hereby give my informed consent for treatment.

GENERAL CONSENT SIGNATURE *

clear

WELCOME TO OUR OFFICE

We would like to welcome you as a patient. Your dentist has already advised you that you may have periodontal disease in process. Your initial visit to our office will consist of obtaining thorough medical and dental history, a full mouth examination, and the taking of x-rays, if necessary. A description of the extent of your problems will be discussed, as well as a prognosis, estimated fee and time required for treatment. You will be encouraged to ask any questions you may have regarding your situation and treatment. Remember, you, your dentist and our staff are here to work as a team in the control of your periodontal disease.

Fees and Payments: All co-pays and deductibles are due at time of service. We offer 6 different payment options:

Cash
Check
Visa or MasterCard
Debit Card w/Visa or MasterCard Logo
American Express
Care Credit / Financing

Missed Appointments: We require at least 48 hours in advance to cancel or re-schedule any appointments made. Our policy is to charge $200 for missed appointments. Please help us serve you better by keeping your scheduled appointments.

Insurance: Please remember that insurance companies DO NOT attempt to cover ALL DENTAL COSTS. Most companies pay fixed portions of the full charges. It is your responsibility to pay all deductible amounts, co-insurance, and any other balance not paid for by your insurance company. If your insurance company has not paid your account in full within 45 days, the balance is your responsibility. Please be aware that some, and perhaps all of the services, may not be covered services and may therefore not be considered reasonable and necessary by your insurance company.

We are Providers for the following Insurance Plans (for an updated list please visit our website):

Culinary A option - after referral from your primary general dentist
Diversified Dental Network
Delta Dental Premier

We know that questions can arise on insurance matters. We encourage you to discuss such questions with our office staff. We will be happy to help you receive maximum benefits. However, the agreement of the insurance company to pay for your dental care is an agreement between you and your insurance company. We bill your insurance company as a courtesy to you. Here's what we need to be able to do so:

Driver's License or Picture l.D.
Insurance Card/s
Insurance Forms (if any)

If applicable, I authorize the treatment of said minor by Dr. Chen or Dr. Cha for professional services rendered.

Release of information and assignment of benefits:

I authorize the release of any dental and medical information necessary to process this claim and authorize payment of dental benefits to:

Las Vegas Periodontal Care / The Dental Implant Institute a.k.a. Dr. Leon Chen or Dr. Jennifer Cha.

I understand that I am financially responsible for charges not covered by my insurance and I or charges not paid promptly by my insurance company. I also understand that 1.5% of the total balance may be applied as monthly interest to my account, if balance is not paid within 90 days.

WELCOME TO OUR OFFICE SIGNATURE *

clear

PATIENT BILL OF RIGHTS AND PATIENT RESPONSIBILITIES

Please read and sign this Patient Bill of Rights and Patient Responsibilities
at the end. Your signature indicates that you have read, understand and agree
with each of the points in this Patient Bill of Rights and Patient Responsibilities. If you have any questions about any of the points below, ask your treatment coordinator before you sign the acceptance of this document.

The Dental Implant Institute of Las Vegas, Inc. and all of its affiliated dental professionals (collectively, "Dll" ) promise to deliver dental care to you, the patient (" Patient" ) that meets or exceeds the standard of care for dental services in the community. Our goal is Patient satisfaction.
Dll promises to treat you and your family members with respect and to fully explain any procedure and the risks associated with any procedure. You will be assigned a treatment coordinator who will be able to assist and deal with any issues that may arise from time to time. This person will be in periodic contact during the period of treatment. If you or any member of your family has any questions or problems, you agree to immediately notify the coordinator assigned to you so that the issues can be immediately addressed. Unless you or your family members advise us of any issue at the time it arises, you as the patient will be fully responsible for the consequences of that issue. Dll can only handle problems we know about. The earlier we know about a concern, the more likely we will be able to satisfactorily address the situation in a meaningful way.
Dll acknowledges that the procedures although providing significant benefits to patients can be very costly. Additionally, we acknowledge that some patients may feel intimidated once treatment begins to speak up and express their concerns. Moreover, we also understand that when a patient is older, some may question the merits and cost of any medical or dental procedure that is not life threatening. Before agreeing to any course of treatment, we strongly recommend that you review your financial situation and discuss it along with benefits of treatment with t hose involved with your finances, adult children in the case of older patients, and spouses. Unless you notify t he patient coordinator, you are representing that you have thought through the financial consequences and the benefits of the proposed treatment and consulted with those who are involved with your life before electing to move forward with treatment.
It is important to understand that dentistry is not an exact science and even if all of the procedures are followed precisely, it is still possible that a course of treatment may not succeed. The human body is not predictable and sometimes can reject an evasive procedure. While Dll and its affiliated professionals will use
all commercially reasonable efforts used in the practice of dentistry to ensure success, it is impossible to guarantee success, a percentage of success or predict how the human body may react. In the majority of cases we will succeed to some degree, but it is not possible for complete success in every situation.
Dental treatment is a partnership between the patient and the dental professionals. To maximize the chances of success, both the patient and the dental professionals have to work together. This means you must comply with all after care instructions and show up for appointments. Many problems that could develop can be avoided if spotted and treated immediately. The appointment can spot issues and immediately deal with them as needed. If a patient fails to follow after care instruction or show up for appointments, the patient shall be responsible for any additional costs incurred to correct problems that could have been prevented had the aftercare instructions been followed and/or the patient showed up for all of his or her appointments.
Dll will not begin any treatment unless the patient has signed an informed consent that explains in writing the scope of treatment and the cost of treatment and also completed a medical questionnaire. Since it is not always possible to determine the extent of treatment required until treatment begins, the scope of treatment may be modified and be expanded or reduced. The informed
consent that each patient signs will try to disclose any additional treatment that could be required and/or discovered during a procedure as well as the cost associated with such additional services. If the course of treatment is.going to be modified, you will be requested when you are of sound mind and not under the
influence of any drug to execute a modified informed consent . If you do not want the dental professional to address additional problems discovered during a procedure and address them during that procedure, you will need to notify the patient coordinator before the dental professional begins working on you. Please
understand that we will not do anything not specified unless the dental professional believes it is in the patient's best interest.
Informed consent is meaningless unless the patient is not under the influence of any legal or illegal substance that can impair judgment. Patient understands and agrees that they will not sign any informed consent if they have taken any illegal or legal drug or alcohol that could impair their judgment.
Patient must fully and accurately complete the medical questionnaire. Unless a Patient fully and truthfully discloses on the medical questionnaire, the Patient and not Dll will be fully responsible for the ramifications of any treatment resulting from an incomplete or incorrect medical questionnaire.
Dll is on the cutting edge of dental technology and regularly holds seminars to educate dental professionals in the latest developments in dentistry. Other prospective patients also often look to see the results of others and photographs and video images can be helpful. The use of photographs and video tapes are important educational devices that can improve dentistry. You authorize the anonymous use of your image in photographs and video in educational seminars,
in advertisements at health fairs, in medical journals, in magazines, in newspapers, on the internet, without any prior consent and without payment of any form of compensation.
Dll strives to address the needs of every patient and potential patient. Often times, patients come to us to evaluate, complete or re-do dental work performed by other dental professionals. If any of the dental services involve completion or re-doing the work of other dental professions, Dll although it will use all commercially reasonable efforts in dentistry to address the issues, is not responsible for the work or consequences of the dental work performed by others.
Dll has a staff of experienced dental professionals with extensive experience. It cannot guarantee that a specific professional will handle specific aspects of the treatment. In some instances some aspects of the work may be performed by support personnel operating under the supervision of a licensed dentist.
If a patient elects to discontinue treatment for any reason, Dll will refund any prepayments made for work not completed. However, the patient remains responsible for the cost of all products and services completed before the termination of treatment. The cost of the completed services and products would include but not be limited to laboratory services and other completed work even if not installed into the mouth. In the event of discontinued treatment, all completed work will be repriced at the usual, customary and reasonable rate meaning that any discounts or credits will not apply to the amount the patient will be held responsible. In the event of discontinued treatment, it is important for the patient to acknowledge that the discontinuation can put the patient at great risk. Consequently, Dll cannot be responsible for anything that may occur as a result of the discontinuation of treatment.

PATIENT BILL OF RIGHTS AND PATIENT RESPONSIBILITIES ACKNOWLEDGEMENT

I certify under penalty of perjury that I am executing this Patient Bill of Rights and Patient Responsibilities consisting of items 1-12and including the acknowledgement below voluntarily and am not under the influence of any drug, alcohol or anything else that may impair my judgment. In addition, I acknowledge that I had an opportunity to ask any questions that I had and to the extent I had questions, they were satisfactorily answered by the treatment coordinator.

PATIENT BILL OF RIGHTS AND PATIENT RESPONSIBILITIES SIGNATURE *

clear

ALL PATIENT FORMS & CONSENTS CONFIRM AND SUBMIT

I understand that the information I have given today is correct to the best of my knowledge. I also understand that the information will be held in the strictest confidence and it is my responsibility to inform the office of any changes in my medical status. I authorize the dental staff to perform any additional dental services that I may need during diagnosis and treatment with my informed consent. *

clear

Enter the word in the image and click submit to complete form (is not case sensitive) *
captcha

Report abuse

New Patient Information

Patient Contact Information

Emergency Contact Information

Patient Insurance Information

Secondary Insurance

Medical History

For Women

Reason(s) for seeing the dentist today

Diseases or Medical Problems

Heart and Circulatory Problems

Breathing/Lung Problems

Stomach Problems

Mental Health Problems

Muscle and Bone Problems

Liver Problems

Neurologic Problems

Blood Problems

Other Problems

Allergies

H.l.P.A.A. NOTICE OF PRIVACY PRACTICES

GENERAL CONSENT

WELCOME TO OUR OFFICE

PATIENT BILL OF RIGHTS AND PATIENT RESPONSIBILITIES

ALL PATIENT FORMS & CONSENTS CONFIRM AND SUBMIT