Patient Registration - Encino dentist Dr. Isaac Comfortes, D.D.S.

16133 Ventura Blvd Suite 1240, Encino, CA 91436

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16133 Ventura Blvd Suite 1240, Encino, CA 91436

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Dental History
WELCOME!
So that we may provide you with the best possible care, please complete this medical history form. All information is completely confidential.
Patient FIrst Name*
Patient Last Name*
Contact Email*
What is the reason for your visit today?
Medical Alert
Date of Last Dental Visit
MM slash DD slash YYYY
Last Dental Cleaning
MM slash DD slash YYYY
Last Full Mouth X-rays
MM slash DD slash YYYY
What was done at your last dental visit?
Previous Dentist's Name
Address
Street Address State ZIP Code
Telephone
How often do you have dental examinations?
How often do you brush your teeth?
How often do you floss?
What other dentai aids do you use? (Mechanical toothbrush, etc.)
Do you have any dental problems now?
- Yes
- No
If yes, please describe:
Are any of your teeth sensitive to:
Hot or cold?
- Yes
- No
Sweets?
- Yes
- No
Biting or Chewing?
- Yes
- No
Have you noticed any mouth odors or bad tastes?
- Yes
- No
Do you frequently get cold sores, blisters or any other oral lesions?
- Yes
- No
Do your gums bleed or hurt?
- Yes
- No
Have your parents experienced gum disease or tooth loss?
- Yes
- No
Have you noticed any loose teeth or change in your bite?
- Yes
- No
Does food tend to become caught in between your teeth?
- Yes
- No
If yes, where?
Do you:
Clench or grind your teeth while awake or asleep?
- Yes
- No
Bite your lips or cheeks regularly?
- Yes
- No
Hold foreign objects with your teeth? (pencils. pipe, pins, nails, fingernails)
- Yes
- No
Mouth breathe while awake or asleep?
- Yes
- No
Have tired jaws, especially in the morning?
- Yes
- No
Smoke/chew tobacco?
- Yes
- No
Have you ever had:
Orthodontic treatment?
- Yes
- No
Oral surgery?
- Yes
- No
Periodontal treatment?
- Yes
- No
A bite plate or mouth guard?
- Yes
- No
A serious injury to the mouth or head?
- Yes
- No
If so, please describe, including cause
Clicking or popping of the jaw?
- Yes
- No
Pain? (joint, ear, side of face)
- Yes
- No
Difficulty in opening or closing the mouth?
- Yes
- No
Difficulty in chewing on either side of the mouth?
- Yes
- No
Headaches, neck aches or shoulder aches?
- Yes
- No
Sore muscles (neck, shoulders)?
- Yes
- No
Are you satisfied with your smile?
- Yes
- No
If not what would you like to do?
Do you feel nervous about having dental treatment?
- Yes
- No
If so, what is your biggest concern?
Have you ever had an upsetting dental experience?
- Yes
- No
If yes, please describe
Is there anything else about having dental treatment that you would like us to know?
- Yes
- No
If yes, please describe

Medical History
Have you been under the care of a medical doctor during the past two years?
- Yes
- No
If yes, for what?
Physician's Name
First Last
Phone
Address
Street Address City State ZIP Code
Have you taken any medication or drugs during the past two years?
- Yes
- No
Are you taking any medication, drugs or pills now?
- Yes
- No
Name Dosage
Have you ever taken prescription medications for weight loss (diet pills)?
- Yes
- No
If yes, did you take any of the following:
- Fen-Phen (Fenfluramine-Phenpermine)
- Pondimen (Fenfluramine)
- Redux (Dexfenfluramine)
If yes to any of the above, did you have a medical exam for heart issues?
- Yes
- No
Are you aware of having an allergic (or adverse reaction) to any medication or substance?
- Yes
- No
If yes, please list:
Have you been a patient in the hospital during the past five years?
- Yes
- No
Indicate which of the following you have had, or have at the present.
- Heart (Surgery, Disease, Attack)
- Chest Pain
- Congenital Heart Disease
- Heart Murmur
- High Blood Pressure
- Mitral Valve Prolapse
- Artificial Heart Valve
- Heart Pacemaker
- Rheumatic fever
- Arthritis/Rheumatism
- Cortisone Medicine
- Swollen Ankles
- Stroke
- Diet (Special Restricted)
- Artificial Joints (hip, knee, etc.)
- Kidney Trouble
- Ulcers
- Diabetes
- Thyroid Problems
- Glaucoma
- Contact Lens
- Emphysema
- Tuberculosis
- Asthma
- Hay Fever
- Allergic To Any Metal
- Latex Sensitivity
- Allergies or Hives
- Sinus Trouble
- Radiation Therapy
- Chemotherapy
- Tumors
- Hepatitis A (infectious), B (serum), C
- Venereal Disease
- A.I.D.S.
- H.I.V Positive
- Cold Sores/Fever Blisters
- Blood Transfusion
- Hemophilia
- Sickle Cell Disease
- Bruise Easily
- Liver Disease
- Yellow Jaundice
- Neurological Disorders
- Epilepsy or Seizures
- Fainting or Dizzy Spells
- Nervous/Anxious
- Psychiatric/Psychological Care
Do you use more than two pillows to sleep?
- Yes
- No
Have you lost or gained more than 10 pounds in the last year?
- Yes
- No
Do you have or have you had any disease, condition, or problem not listed?
- Yes
- No
If yes, please list:
Women Are you:
Pregnant?
- Yes
- No
Number of months pregnant
Nursing?
- Yes
- No
Taking birth control pills?
- Yes
- No
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release such information to you. I will notify the doctor of any change in my health or medication.
Patient/Guardian Signature
Date
MM slash DD slash YYYY

PATIENT REGISTRATION
YOUR INFORMATION
Date
MM slash DD slash YYYY
Name
Last First M.I.
Prefers to be called by
Address
Street Address City State ZIP Code
Home Phone No.
E-mail
Birth Date
MM slash DD slash YYYY
Age
- Male
- Female
- Married
- Single
- Divorced
- Widowed
Social Security No.

YOUR CHILD'S INFORMATION
Date
MM slash DD slash YYYY
Name
Last First M.I.
Prefers to be called by
Address
Street Address City State ZIP Code
Home Phone No.
Birthday
MM slash DD slash YYYY
Age
- Male
- Female
- Married
- Single
- Divorced
- Widowed
Social Security No.
(If your child's last name and/or address are not the same as yours, fill in the top section also.)

Dental Insurance
Primary Carrier
Insurance Co.
Group No.
Employer Name
Insured's Name
First Last
Date of Birth
MM slash DD slash YYYY
Relationship To Patient
Insured's I.D. No.
Insured's Social Security No.
Second Carrier
Insurance Co.
Group No.
Employer Name
Insured's Name
First Last
Date of Birth
MM slash DD slash YYYY
Relationship To Patient
Insured's I.D. No.
Insured's Social Security No.

Account Information
Person Financially Responsible For Account
Name
First Last
Relationship to Patient
Social Security No.
Address
Street Address City State ZIP Code
Phone No.
YOU:
Name
First Last
Occupation
Employer's Name
Address
Street Address City
Phone No.
Fax No.
E-mail
YOUR SPOUSE:
Name
First Last
Occupation
Employer's Name
Address
Street Address City
Phone No.
Fax No.
E-mail

GETTING TO KNOW YOU
Is another member of your family or relative a patient at our office?
Name:
First Last
Relationship:
You Were Referred To Us By:
Your Former Address:
Street Address City State ZIP Code
Person To Contact For Emergency
First Last
Phone Number
Address
Street Address City State ZIP Code
Closest Relative Not Living With You
First Last
Phone Number
Address
Street Address City State ZIP Code

CONSENT FOR TREATMENT
I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of
(name of patient)
First Last
dental needs.

Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates. I understand that a 1-1/2% late charge (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made.
Patient's Signature
Date
MM slash DD slash YYYY
Witness
Parent/Responsible Party's Signature
Relationship to Patient

Payment Policy
In order to insure that you are able to maintain your dental integrity and health, it is our intent, whenever possible, to be able to provide you with flexible payment arrangements.

As a reminder, office policy is that PAYMENT IS REQUESTED AT THE TIME OF YOUR DENTAL VISIT. As a convenience to our patients, we have now expanded our policy to include the following payment options:
- Payment by cash
- Payment by check
- Payment by credit card
- Convenient automatic monthly billing to your Visa, MasterCard, Discover or American Express (billing period not to exceed 90 days)
Please indicate your choice of payment, sign and date below, and return to our Business Administrator, prior to commencing treatment.
Signature
Date
MM slash DD slash YYYY

NOTICE OF PRIVACY PRACTICES

Isaac N. Comfortes, D.D.S (818) 990-9101

Protecting Your Confidential Health Information is Important to Us

Notice of Privacy Practices

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.

Our Promise!

Dear Patient:
This is not meant to alarm you! Quite the opposite! It is our desire to communicate to you that we are taking the new Federal (HIPAA - Health Insurance Portability and Accountability Act) laws written to protect the confidentiality of your health information seriously. We do not ever want you to delay treatment because you are afraid your personal health history might be unnecessarily made available to others outside of our office.
So what has changed
Why a privacy policy now?
Very good question!

The most significant variable that has motivated the Federal government to legally enforce the importance of the privacy of health information is the rapid evolution of computer technology and its use in healthcare. The government has appropriately sought to standardize and protect the privacy of the electronic exchange of your health information. This has challenged us to review not only how your health information is used within our computers but also with the Internet, phone, faxes, copy machines, and charts. We believe this has been an important exercise for us because it has disciplined us to put in writing the policies and procedures we use to ensure the protection of your health information everywhere it is used.

We want you to know about these policies and procedures which we developed to make sure your health information will not be shared with anyone who does not require it. Our office is subject to State and Federal law regarding the confidentiality of your health information and in keeping with these laws, we want you to understand our procedures and your rights as our valuable patient.

We will use and communicate your HEALTH INFORMATION only for the purposes of providing your treatment, obtaining payment and conducting health care operations. Your health information will not be used for other purposes unless we have asked for and been voluntarily given your written permission.

How your HEALTH INFORMATION may be used

To Provide Treatment

We will use your HEALTH INFORMATION within our office to provide you with the best dental care possible. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between hygienist, dental assistant, dentist, and business office staff. In addition, we may share your health information with physicians, referring dentists, clinical and dental laboratories, pharmacies, or other health care personnel providing you treatment.

To Obtain Payment

We may include your health information with an invoice used to collect payment for treatment you receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically. We will be sure to only work with companies with a similar commitment to the security of your health information.

To Conduct Health Care Operation

Your health information may be used during performance evaluations of our staff. Some of our best teaching Oppol1unities use clinical situations experienced by patients receiving care at our office. As a result, health information may be included in training programs for students, interns, associates, and business and clinical employees. It is also possible that health information will be disclosed during audits by insurance companies or government appointed agencies as part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine processes of certification, licensing or credentialing activities.

In Patient Reminders

Because we believe regular care is very important to your oral and general health, we will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up on our care and inform you of treatment options or services that may be of interest to you or your family.

These communications are an important part of our philosophy of partnering with our patients to be sure they receive the best preventive and restorative care modern dentistry can provide. They may include postcards, folding postcards, letters, telephone reminders or electronic reminders such as email (unless you tell us that you do not want to receive these reminders).

Protecting Your Confidential Health Information is Important to Us
Abuse or Neglect

We will notify government authorities if we believe a patient is the victim of abuse, neglect or domestic violence. We will make this disclosure only when we are compelled by our ethical judgment, when we believe we are specifically required or authorized by law or with the patient's agreement.

Public Health and National Security

We may be required to disclose to Federal officials or military authorities health information necessary to complete an investigation related to public health or national security. Health information could be important when the government believes that the public safety could benefit when the information could lead to the control or prevention of an epidemic or the understanding of new side effects of a drug treatment or medical device.

For Law Enforcement

As permitted or required by State or Federal law, we may disclose your health information to a law enforcement official for certain law enforcement purposes, including. under certain limited circumstances, if you are a victim of a crime or in order to report a crime.

Family, Friends and Caregivers

We may share your health information with those you tell us will be helping you with your home hygiene, treatment, medications, or payment. We will be sure to ask your permission first. In the case of an emergency, where you are unable to tell us what you want we will use our very best judgment when sharing your health information only when it will be important to those participating in providing your care.

Authorization to Use or Disclose Health Information

Other than is stated above or where Federal, State or Local law requires us, we will not disclose your health information other than with your written authorization. You may revoke that authorization in writing at any time.

Patient Rights

This new law is careful to describe that you have the following rights related to your health information.

Restrictions

You have the right to request restrictions on certain uses and disclosures of your health information. Our office will make every effort to honor reasonable restriction preferences from our patients.

Confidential Communications

You have the right to request that we communicate with you in a certain way. You may request that we only communicate your health information privately with no other family members present or through mailed communications that are sealed. We will make every effort to honor your reasonable requests for confidential communications.

Inspect and Copy Your Health Information

You have the right to read, review, and copy your health information, including your complete chart, x-rays and billing records. If you would like a copy of your health information, please let us know. We may need to charge you a reasonable fee to duplicate and assemble your copy.

Amend Your Health Information

You have the right to ask us to update or modify your records if you believe your health information records are incorrect or incomplete. We will be happy to accommodate you as long as our office maintains this information. In order to standardize our process, please provide us with your request in writing and describe your reason for the change.

Your request may be denied if the health information record in question wa not created by our office, is not part of our records or if the records containing your health information are determined to be accurate and complete.

Documentation of Health Information

You have the right to ask us for a description of how and where your health information was used by our office for any reason other than for treatment, payment or health operations. Our documentation procedures will enable us to provide information on health information usage from April 14,2003 and forward. Please let us know in writing the time period for which you are interested. Thank you for limiting your request to no more than six years at a time. We may need to charge you a reasonable fee for your request.

Request a Paper Copy of this Notice

You have the right to obtain a copy of this Notice of Privacy Practices directly from our office at any time. Stop by or give us a call and we will mail or email a copy to you.

We are required by law to maintain the privacy of your health information and to provide to you and y ur representative this Notice of our Privacy Practices. We are required to practice the policies and procedures described in this notice but we do reserve the right to change the terms of our Notice. If we change our privacy practices we will be sure all of our patients receive a copy of the revised Notice.

You have the right to express complaints to us or to the Secretary of Health and Human Services if you believe your privacy rights have been compromised. We encourage you to express any concerns you may have regarding the privacy of your information.
Patient Acknowledgment
Patient Name(s)
Thank you very much for taking time to review how we are carefully using your health information. If you have any questions we want to hear form you. If not, we would appreciate very much your acknowledging your receipt of our policy by signing and returning this card. We look forward to seeing you again soon!
Patient Signature

Patient Signature
Date
MM slash DD slash YYYY

Date
Name
This field is for validation purposes and should be left unchanged.

91298

The general, cosmetic and reconstructive dental practice of Encino dentist Dr. Isaac Comfortes is devoted to restoring optimal oral health, which supports whole body health and enhances the natural beauty of smiles.

Office Hours

Monday - Thursday : 7:30am - 4:00pm

Friday : Closed

Saturday - Sunday : Closed

Location

16133 Ventura Blvd Suite 1240, Encino, CA 91436

info@isaaccomfortesdds.com

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© 2024 Encino dentist Dr. Isaac Comfortes, D.D.S.

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