New Patient Paperwork New Patient Registration (LIVE) Electronic Forms Step 1 of 11 - Welcome 9% [Admin] Document IDThank you for choosing Founders Park Dentistry to provide you with dental services. This digital form will help us to record your data in our system more accurately. It will reduce the chance of medical and clerical errors associated with the traditional paper forms.The following will be helpful in filling out the forms Dental insurance cards for all insurance companies you would like us to file for you. List of Medications Social Security Number for Financial Responsible Party Notice of Privacy Policies Please Read and Sign Below 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. We are required by law to provide you with this notice that explains our privacy practices with regard to your medical information and how we may use and disclose your protected health information for treatment, payment, and for health care operations, as well as for other purposes that are permitted or required by law. You have certain rights regarding the privacy of your protected health information and we also describe those rights in this notice. Ways in Which We May Use and Disclose Your Protected Health Information: The following paragraphs describe different ways that we use and disclose your protected health information. We have provided an example for each category, but these examples are not meant to be exhaustive. All of the ways we are permitted to use and disclose your health information fall within one of these categories. Treatment We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. We will also disclose your health information to other physicians who may be treating you. Additionally we may from time to time disclose your health information to another physician whom we have requested to be involved in your care. For example – we would disclose your health information to a specialist to whom we have referred you for a diagnosis to help in your treatment. Payment We will use and disclose your protected health information to obtain payment for the health care services we provide you. For example — we may include information with a bill to a third-party payer that identifies you, your diagnosis, procedures performed, and supplies used in rendering the service. Health Care Operations We will use and disclose your protected health information to support the business activities of our practice. For example -– we may use medical information about you to review and evaluate our treatment and services or to evaluate our staff’s performance while caring for you. In addition, we may disclose your health information to third party business associates who perform billing, consulting, or transcription, or other services for our practice. Other Ways We May Use and Disclose Your Protected Health Information: Appointment Reminders We will use and disclose your protected health information to contact you as a reminder about scheduled appointments or treatment. Treatment Alternatives We will use and disclose your protected health information to tell you about or recommend possible alternative treatments or options that may be of interest to you. Others Involved in Your Care We will use and disclose your protected health information to a family member, a relative, a close friend, or any other person you identify that is involved in your medical care or payment for care. Research We will use and disclose your protected health information to researchers, provided the research has been approved by an institutional review board that has reviewed the research proposal and established protocols to ensure the privacy of your health information. As Required by Law We will use and disclose your protected health information when required to by federal, state, or local law. To Avert a Serious Threat to Public Health or Safety We will use and disclose your protected health information to public health authorities permitted to collect or receive the information for the purpose of controlling disease, injury, or disability. If directed by that health authority, we will also disclose your health information to a foreign government agency that is collaborating with the pubic health authority. Worker’s Compensation We will use and disclose your protected health information for worker’s compensation or similar programs that provide benefits for work-related injuries or illness. Inmates We will use and disclose your protected health information to a correctional institution or law enforcement official if you are an inmate of that correctional institution or under the custody of the law enforcement official. This information would be necessary for the institution to provide you with health care; to protect the health and safety of others; or for the safety and security of the correctional institution. Your Health Information Rights Although your health record is the physical property of the practitioner or facility that compiled it, the information belongs to you. You have the right to: A Paper Copy of This Notice. You have the right to receive a paper copy of this notice upon request. You may obtain a copy by asking our receptionist at your next visit or by calling and asking us to mail you a copy. Inspect and Copy You have the right to inspect and copy the protected health information that we maintain about you in our designated record set for as long as we maintain that information. This designated record set includes your medical and billing records, as well as any other records we use for making decisions about you. Any psychotherapy notes that may have been included in records we received about you are not available for your inspection or copying, by law. We may charge you a fee for the costs of copying, mailing, or other supplies used in fulfilling your request. If you wish to inspect or copy your medical information, you must submit your request in writing to our Privacy Officer: Attention: Privacy Officer, 6801 Isaacs Orchard Rd., Suite 101, Springdale, AR 72762. Phone: (479) 717-2904. You may mail your request, or bring it to our office. We will have 30 days to respond to your request for information that we maintain at our practice site. If the information is stored off-site, we are allowed up to 60 days to respond but must inform you of this delay. Request Amendment You have the right to request that we amend your medical information if you feel that it is incomplete or inaccurate. You must make this request in writing to our practice manager, stating exactly what information is incomplete or inaccurate and the reasoning that supports your request. We are permitted to deny your request if it is not in writing or does not include a reason to support the request. We may also deny your request if: The information was not created by us, or the person who created it is no longer available to make the amendment. The information is not part of the record which you are permitted to inspect and copy. The information is not part of the designated record set kept by this practice or if it is the opinion of the opinion of the health care provider that the information is accurate and complete. Request Restrictions You have the right to request a restriction of how we use or disclose your medical information for treatment, payment, or health care operations. For example – you could request that we not disclose information about a prior treatment to a family member or friend who may be involved in your care or payment for care. Your request must be made in writing to our practice manager. We are not required to agree to your request if we feel it is in your best interest to use or disclose that information. If we do agree, we will comply with your request except for emergency treatment. An Accounting of Disclosures You have the right to request a list of the disclosures of your health information we have made outside of our practice that were not for treatment, payment, or health care operations. You request must be in writing and must state the time period for the requested information. You may not request information for any dates prior to April 14, 2003, nor for a period of time greater than six years (our legal obligation to retain information). Your first request for a list of disclosures within a 12-month period will be free. If you request an addition list within 12-months of the first request, we may charge you a fee for the costs of providing the subsequent list. We will notify you of such costs and afford you the opportunity to withdraw your request before any costs are incurred. Request Confidential Communications You have the right to request how we communicate with you to preserve your privacy. For example – you may request that we call you only at your work number, or by mail at a special address or postal box. Your request must be made in writing and must specify how or where we are to contact you. We will accommodate all reasonable requests. File a Complaint If you believe we have violated your medical information privacy rights, you have the right to file a complaint with our practice or directly to the Secretary of Heath and Human Services. To file a complaint with our manager, you must make it in writing within 180 days of the suspected violation. Provide as much detail as you can about the suspected violation and send it to our Privacy Officer. Uses or Disclosures Not Covered Uses or disclosures of your health information not covered by this notice or the laws that apply to us may only be made with your written authorization. You may revoke such authorization in writing at any time and we will no longer disclose health information about you for the reasons stated in your written authorization. Disclosures made in reliance on the authorization prior to the revocation are not affected by the revocation. For More Information If you have questions or would like additional information, you may contact our Privacy Officer. Receipt of Privacy Practices*By signing this form, you have received a copy of our Privacy Practices Our Financial Policy Thank you for choosing Founders Park Dentistry. One of the most important aspects of maintaining a long term relationship is good communication from the beginning. We have found that many people do not have a full understanding on how insurance works. In order avoid any miscommunications down the road we wanted to share our financial policy with you now. If you have any questions about our policy or how insurance works please ask our team members at anytime.Please check each item to confirm you have read these policies. By signing this document you agree to all policies listed below.* Your dental benefits are based upon a contract made between your employer and an insurance company. If you have any questions regarding your dental benefits, please contact your employer or insurance company directly. Dental benefit plans will never pay for completion of your dental care. It is meant only to assist you. WE WILL BILL YOUR INSURANCE AS A COURTESY. If your insurance does not pay within 30 days, we reserve the right to request payment in full for services from you and let you collect the insurance funds that are due to you. This is rare, but is important that you recognize that the insurance you have is a legal contract between you and your insurance company. Our office is not, and cannot be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office. Although we can maintain computerized histories of payment by a given insurance company, they do change; therefore, it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most current information we have, but it is ONLY AN ESTIMATE. A specific amount of time is reserved especially for you, and we strongly encourage all patients to keep their appointment. We require at least a 48-HOUR NOTICE TO AVOID A CANCELLATION CHARGE of $50 PER HOUR THAT YOU ARE SCHEDULED. A $25 charge may be incurred on returned checks. In the event that an account is turned over to an outside collection agency for collection, the patient is responsible for all collection/attorney fees incurred by Robert Stark, DDS, PA as a result of non-payment. I hereby authorize the release of any information, including the diagnosis and records of any treatments, x- rays, photographs, or examinations rendered, to my insurance company. I hereby authorize my insurance company to pay directly to Robert Stark, D.D.S PA (DBA Founders Park Dentistry) and any proceeds payable under the terms of my insurance policy. I hereby authorize Dr. Robert Stark to perform dental procedures on me, my minor children, and/or family members. Financial Policies Signature Patient InformationPatient InformationPlease enter information about the person being seen in our office here.Patients Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Patient Date of Birth*Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Gender*MaleFemaleI prefer to be calledAddress* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Communications With Our Office Our cloud based dental software relies on modern technologies such as email and text messages to provide you with timely reminders for dental appointments and cleanings. Your email address will not be shared with other parties or be abused by us.Mobile Phone*Home PhonePatient Email This is the email address which will receive appointment and cleaning remindersEmergency Contact Name:*Emergency Contact Phone Number:* Responsible Party Who will be financially responsible for charges incured at Founders Park DentistryPatientSomeone ElseIf the patient is 18 years of age or older, they are their own responsible party. "Someone else" indicates a parental guardian of a minor or someone with legal guardianship of a patient unable to care for themselves. Patient Social Security Number*Responsible Party InformationResponsible Party Name* Mr.Mrs.MissMs.Dr.Prof.Rev. Prefix First Last Suffix Responsible Party Birthdate:* MM DD YYYY Responsible Party Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code This is where the account statements will be sent toResponsible Party Social Security Number*Responsible Party Phone*This Phone Number is a*Home Phone NumberMobile Phone NumberWork Phone NumberOtherAdditional PhoneThis Phone Number is aHome Phone NumberMobile Phone NumberWork Phone NumberOtherResponsible Party Email Will there be any insurance filed?*No InsuranceOne PlanTwo PlansMore Than Two PlansIt is rare that there would be more than two insurance policies filed for a single person. Fill out the form for two policies. Please bring your information for the additional policies with you.Primary Insurance InformationnPrimany Insurance Company Name*Information of the person who holds the insurance policy.Insurance Policy Holder Name* Insurance Policy Holder Date of Birth* Information of the person who holds the insurance policy.Member ID ( or Subscriber ID)*See the back of insurance card for thisGroup NumberSee the back of insurance card for thisInsurance Company Phone*See Your Insurance Card for this numberRelation of Insured (Patient) to Policy Holder*SelfHusbandWifeFatherMotherLegal GuardianWhat is the relationship of the patient to the person who holds this insurance policy?Job Title:*Employer Name*Only enter this if the insurance policy is through your employer rather than a individual plan. Employer Phone Number*Employer Address Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Secondary Insurance InformationSecondary Insurance Company Name*Insurance Policy Holder Name* Information of the person who holds the insurance policy.Insurance Company PhoneSee Your Insurance Card for this numberInsurance Policy Holder Date of Birth* Information of the person who holds the insurance policy.Member ID (or Subscriber ID)*See the back of insurance card for thisGroup NumberSee the back of insurance card for thisRelation of Insured (Patient) to Policy Holder*SelfWifeHusbandFatherMotherLegal GuardianWhat is the relationship of the patient to the person who holds this insurance policy?Employer NameOnly enter this if the insurance policy is through your employer Dental HistoryAre you having any discomfort at this time?*YesNoPlease ExplainWhat are your Chief Concerns? Please check all that apply Pain Avoidance Appearance Losing Teeth Gum/Periodontal Disease Cavities Bad Breath Missing Teeth Routine Checkup/Cleaning Are you happy with the appearance of your teeth?*YesNoWhat would you like to change?Does Dental Treatment Make you Nervous*NoSlightlyModeratelyExtremelyHave you ever been treated for periodontal disease (gum disease)?*YesNoThis is includes deep cleanings (scaling and root planning), gum surgeries, etc.How often do you brush?Your toothbrush is?*SoftMeduimHardElectricNot SureDo you floss?*YesNoHow often?When was your last dental visit?*Mouth: I have the following: (Check All That Apply)Bleeding, sore gumsUnpleasant taste/bad breathBurning tongue/lipsFrequent blisters, lips/mouthSwelling/lumps in the mouthTeeth: I have the following... (Check any that apply)Sensitivity to hotSensitivity to coldSensitivity to sweetsSensitivity to bitingLoose TeethJoint/Muscle Issues: I have the following (Check all that apply)Difficulty opening or closing jawClenching/grindingClicking/popping jawChange/Shift in bite Medical HistoryYour Physician's NamePhysician's Phone NumberAre you being treated by him/her at this time?YesNoPlease ExplainApproximate Date of Last Visit?Month123456789101112Day12345678910111213141516171819202122232425262728293031Year201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920Are you allergic to? Penicillin Clindamycin Sulfa Latex Codeine Local Anesthetics List Any Other Allergies:Are You Pregnant?*YesNoAre you nursing?*YesNoAny recent serious illness/hospitalization?*YesNoPlease Explain Please check all conditions you’ve had Past or Present AIDS Anemia Arthritis Artificial Heart valves Artificial Joints Asthma Bleeding abnormally Blood disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Persistant Cough Diabetes Emotional Stress Emphysema/Lung disease Epilepsy Fainting/Dizziness Headaches Heart Disease Heart Murmur Hepatitis-type High Blood Pressure HIV positive Jaundice Kidney disease Liver disease Low Blood Pressure Mitral Valve Prolapse Pacemaker Psychiatric care Radiation treatment Rheumatic fever Scarlet fever Shortness of Breath Sinus Trouble Skin Rash Stroke Swollen Feet/Ankles Swollen Neck Glands Thyroid problems Tuberculosis Tumor or growth Ulcer Venereal disease Unexplained Weight Loss Please list any other diseases/conditions not listed above. Medication ListMedicationTaken forDosage (If Known) Please enter in each medication (and dosages if known) you take and what you take if for.Consent for Treatment*By my signature above, I consent to the examination and treatment by Founders Park Family Dentistry. I understand that dentistry is not an exact science and therefore the results of any treatments performed may vary from patient to patient. I understand that occasionally, additional treatment may be required. Also, by my signature below, I herby certify the correctness and completeness of the medical history information above. I certify that the information provided by me on this Medical Dental history form is correct and complete to the best of my knowledge. I will advise the office of any future changes.Correct answers to the following questions will allow your dentist to treat you on a more individual basis, providing the care appropriate for your particular needs. Your answers are for our records only and will be considered confidentialEmailThis field is for validation purposes and should be left unchanged.