Tamiami Dental Center P.A.

13232 SW 8th St. Miami Fl 33184 305-553-9655 / 305-553-9688

Chart #:
FOR OFFICE USE ONLY

Patient Information Patient Name: Date: Last, First MI Name of Parent or Legal Guardian: ____________________________________________________________________________ Last, First MI Gender: ___________ Social Security #: ________________________ Birth Date: ___________________ Age: ___________ Phone (Home): Address: Street (Work): (Cell): _________________________ ______________________________________________ Apartment #

City State Zip Code Email Address: ___________________________________ how did you hear about us? ________________________________ Health Information Date of Last Dental Visit: Reason for this visit:

Have you ever had any of the following? Please check those that apply: AIDS Allergies Anemia Arthritis Artificial Joints Asthma Blood Disease Cancer Diabetes Dizziness Epilepsy Excessive Bleeding Fainting Glaucoma Growths Hay Fever Head Injuries Heart Disease Heart Murmur Hepatitis High Blood Pressure Jaundice Kidney Disease Liver Disease Mental Disorders Nervous Disorders Pacemaker Pregnancy Due date:_________ Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Sinus Problems Stomach Problems Yes No Yes No Stroke Tuberculosis Tumors Ulcers Venereal Disease Codeine Allergy Penicillin Allergy OTHER: _________________ _________________

Have you ever had any complications following dental treatment? If yes, please explain:

Have you been admitted to a hospital or needed emergency care during the past two years? If yes, please explain: Are you now under the care of a physician? If yes, please explain: Yes No

Name of Physician: _______________________________________________ Phone: Do you have any health problems that need further clarification? If yes, please explain: Yes No

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail. __________________________________________________________ Signature of patient, parent or guardian ______ Date

Tamiami Dental Center P.A.

13232 SW 8th Street. Miami, FL 33184 305-553-9655 / 305553-9688

NOTICE OF PRIVACY PRACTICE As required by the privacy regulation created as a result of the Health Insurance Portability and accountability Act (HIPAA). Our Practice is dedicated to maintain the privacy of your individually identifiable health Information. In conducting our business, we will create records regarding you and the treatment and service we provide you. We are required by law to maintain the confidentiality of health information that identifies you. We also are required by law to provide you with this notice of our legal duties and privacy that we maintain in our practice concerning your Health Information by Federal and State Law. We must follow the terms of the notice of privacy practices that we have in effect at the time. If you have any questions regarding this notice of your health information privacy policy, please contact our office at 305-553-9655. By signing this document I understand and agree with notice. _______________________________ Signature of Patient or Legal Guardian Guardian _______________________________ Name of Patient ________________________________ Print Name of Patient of Legal _________________________________ Date

AVISO ACERCA DE LAS PRCTICAS DE PRIVACIDAD Como es requerido por los reglamentos de privacidad creados como resultado del acta de La Portabilidad y las Responsabilidad de los Seguros de Salud (HIPPA) pos uso siglas en Ingles. Estamos obligado por la ley el mantener la con la confidencialidad de la informacin de salud que identifica su persona. Tambin estamos obligados por la ley el proveerle este aviso respecto a nuestras obligaciones legales de privacidad que mantenemos en nuestra oficina respecto a su informacin de salud. Bajos las leyes federales y estatales tenemos que atenernos a las condiciones del aviso de las prcticas de privacidad que estn en vigencia en este momento. Si tiene preguntas solicite a nuestra oficina de privacidad para aclaraciones. Al firmar este documento, entiendo y estoy de acuerdo con el aviso. _______________________________ Firma del Paciente o Tutor Legal ________________________________ Nombre Del Paciente ______________________________ Nombre del Paciente o Tutor Legal ______________________________ Fecha