Patient Sign-in

Patient Registration Form

Patient Registration( * mandatory to fill )

How do we contact you?( * mandatory to fill )

Please select below

Are you a student?
Yes No
Do you have an Interpreter?
Yes No
Do you have insurance?
Yes No

Employer Information

Please circle your answers below and check the income level (for funding reports only; no names are disclosed):

African Born
African American
Asian/Pacific Islander
Hispanic
Native American
Caucasian
Alaskan Native
Black
Native Hawaiian
American Indian
White
More than one race
Unknown
Other

Who do we contact in case of an emergency?( * mandatory to fill )

Primary Insurance Information( * mandatory to fill )

Responsible Party (Person responsible for paying the bill)( * mandatory to fill )

SELF OTHER

Do you have a Living Will or Advance Directive?
Yes
No
I hereby assign, transfer, and send over to People's Center Health Services all of my rights, title, and interests to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until I give written notice revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance. I hereby authorize treatment deemed necessary by my primary care provider at People's Center Health Service. I authorize the release of my medical records to physicians to which i may be referred.This authorization shall remain valid until I give written notice revoking said authorization.
SIGNATURE
 
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(Your IP Address : )
How Did You Hear About People's Center Health Services?

This is to acknowledge receipt or offering of a copy of PEOPLE'S CENTER HEALTH SERVICES.
Notice of Privacy Practice with an effective date of 01/01/2012.

(Please click below to draw/upload sign)
(Your IP Address : )

*Maybe requested to provide verification of representative status.

For Office Use Only

We made the following efforts to obtain written acknowledgement of receipt of the Notice of Privacy Practices:

However, acknowledgement could not be obtained because:

 Yes     No

Discounted fees are available for individuals or families whose household income falls within o% and 200% of the federal poverty guidelines. If you are interested in applying for discounted services, you will need to provide information about your family and your income so your eligibility can be determined.

Family Size (includes all family members living within the household):

In order to qualify for PCHS' Sliding Fee Discount Program, you need to bring at least one document from the following list. The proof of income must be returned within 30 days of application. If you do not provide your proof of income by the due date, you will have to pay full price for services. The Sliding Fee Discount Program begins on the date your proof of income is received at the clinic. If you do not have any of this documentation, PCHS staff can assist you with self-declaring your income.

Income Validation Document Income Amount Copies Provided
Employment Wages and Earnings Paystub from work (last 30 days)
Self-Employed wage documentation(for last 3 months)
Most current Tax Return
Workers Compensation Statement/Stub
Military leave and earnings Statement/Stub
Employer income statement letter
Patient income statement letter
Benefits Disablility Income Statement/Stub
Current Social Security Statement/Stub
Unemployment Statement/Stub
Other Income Statement of chid support
Most Current Retirement Benefit Statement
Most Current Bank Statement
Other:
Total

Insurance Verification

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(Your IP Address : )
For Office Use Only:

Patient Dental History

 
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No

AUTHORIZATION AND RELEASE

I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION TO THE BEST OF MY KNOWLEDGE. THE ABOVE QUESTIONS HAVE BEEN ACCURATELY ANSWERED. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I AUTHORIZE THE DENTIST TO RELEASE ANY INFORMATION INCLUDING DIAGNOSIS AND THE RECORDS OF ANY TREATMENT OR EXAMINATION RENDERED TO ME OR MY CHILD DURING THE PERIOD OF SUCH DENTAL CARE TO THIRD PARTY PAYORS AND/OR HEALTH PRACTITIONERS. I AUTHORIZE AND REQUEST MY INSURANCE COMPANY TO PAY DIRECTLY TO THE DENTIST OR DENTAL GROUP INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I UNDERSTAND THAT MY DENTAL INSURANCE CARRIER MAY PAY LESS THAN THE ACTUAL BILL FOR SERVICES. I AGREE TO BE RESPONSIBLE FOR PAYMENT TO ALL SERVICES RENDERED ON MY BEHALF OR MY DEPENDENTS.

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(Your IP Address : )
(Please click below to draw/upload sign)
(Your IP Address : )

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your body. Health problems that you may have, or medication that you may be taking, could have an important inter-relationship with the care you will receive. Thank you for answering the following questions.

 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Pregnant/trying to get pregnant  Taking oral contraceptives  Nursing
 Aspirin  Penicillin  Codaine  Acrylic  Metal  Latex  Local anesthetics  Other (if yes please explain)
Do you have or have you had and of the following? Please circle if YES
AIDS/HIV Positive
Yes
No
Alzheimers disease
Yes
No
Anaphylaxis
Yes
No
Anemia
Yes
No
Angina
Yes
No
Arthritis/Gout
Yes
No
Artificial Heart Valves
Yes
No
Artificial Bones/Joints
Yes
No
Asthma
Yes
No
Blood Disease
Yes
No
Blood Transfusion
Yes
No
Breathing Problems
Yes
No
Bruise Easily
Yes
No
Cancer
Yes
No
Chemotheropy
Yes
No
Chest Pain
Yes
No
Cold sores / Fever blisters
Yes
No
Congenital heart disorder
Yes
No
Convulsion
Yes
No
Cortisone medicine
Yes
No
Diabetes
Yes
No
Difficulty Breathing
Yes
No
Drug Addiction
Yes
No
Easily Winded
Yes
No
Emphysema
Yes
No
Epilepsy or Seizures
Yes
No
Excessive Bleeding
Yes
No
Excessive Thirst
Yes
No
Fainting spells / Dizziness
Yes
No
Frequent Cough
Yes
No
Frequent Diarrhea
Yes
No
Frequent Headaches
Yes
No
Genital Herpes
Yes
No
Glaucoma
Yes
No
Hay Fever
Yes
No
Heart Attack / Failure
Yes
No
Heart Murmer
Yes
No
Heart Pacemaker
Yes
No
Heart Trouble / Desease
Yes
No
Hemophilea
Yes
No
Hepatitis A
Yes
No
Hepatitis B or C
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
High Cholesterol
Yes
No
Hives or Rash
Yes
No
Hypoglycemia
Yes
No
Irregular Heartbeat
Yes
No
Kidney Problem
Yes
No
Leukemia
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Lung diseases
Yes
No
Mitral Value prolapse
Yes
No
Osteoporosis
Yes
No
Pain in Jaw Joints
Yes
No
Parathyroid Disease
Yes
No
Psychiatric Care
Yes
No
Radiation Treatments
Yes
No
Recent Weight Loss
Yes
No
Renal Dialysis
Yes
No
Rheumatic Fever
Yes
No
Rheumatism
Yes
No
Scarlet Fever
Yes
No
Shingles
Yes
No
Sickle Cell Disease
Yes
No
Sinus Trouble
Yes
No
Spina Bifida
Yes
No
Stomach/Intestinal Disease
Yes
No
Stroke
Yes
No
Swelling of Limbs
Yes
No
Thyroid Disease
Yes
No
Tonsillitis
Yes
No
Tuberculosis
Yes
No
Tumors or Growths
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Yellow Jaundice
Yes
No
Yes No
Yes No

To the best of my knowledge, the questions on this form have been acurately answered. I understand that providing incorrect information can be dangerous to my (or my patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

(Please click below to draw/upload sign)
(Your IP Address : )
Thank you for visiting People's Center Health Services. We want your visit to be pleasant and comfortable. Please help us by completing this form.
Patient Information

Personal Details

Appointment date:
First Name: Last Name: Date Of Birth: Social Security Number: Gender: Marital Status:

Address

Address: City: State: Zip Code: Home Phone: Cell / Alternative Phone: Driver's License No: State:

Emergency Contact Information

Name: Relation: Home Phone:

Professional Information

Employer: Work Phone: Employer's Address:

Please circle your answers below and check the income level (for funding reports only; no names are disclosed):

African Born African American Asian/Pacific Islander Hispanic Native American Caucasian Alaskan Native Black Native Hawaiian American Indian White More than one race Unknown Other

Details

(includes all family members living within the household)
$0 - $25,000 $25,100 - $50,000 $50,100 - $75,000 $75,100 - $100,000 Over $100,000
Yes No
School name:
Yes No
Intepreter name: Intepreter Phone Number:
Yes No

Insurance Information

Insurance Company Name: Insurance Company Address: Group Number from card: Insured ID#:

Responsible Person for Account

Name: Relation Date of Birth: Address: City: State: Zip Code:

How Did You Hear About People's Center Health Services?

Details Of Organization

Details

Do you have a Living Will or Advance Directive? Yes No
Date of Living Will or Advance Directive:

I hereby assign, transfer, and send over to People's Center Health Services all of my rights, title, and interests to my medical reimbursement benefits under my insurance policy. I authorize the release of any medical information needed to determine these benefits. This authorization shall remain valid until I give written notice revoking said authorization. I understand that I am financially responsible for all charges whether or not they are covered by insurance.

I hereby authorize treatment deemed necessary by my primary care provider at People's Center Health Service. I authorize the release of my medical records to physicians to which i may be referred.This authorization shall remain valid until I give written notice revoking said authorization.

The information on this page is correct to the best of my knowledge.
 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACYPRACTICE

This is to acknowledge receipt or offering of a copy of PEOPLE'S CENTER HEALTH SERVICES.
Notice of Privacy Practice with an effective date of 01/01/2012.

 
 
 
Individual's (or Legal Representative's) Signature DATE & IP ADDRESS

*Maybe requested to provide verification of representative status.

For Office Use Only

We made the following efforts to obtain written acknowledgement of receipt of the Notice of Privacy Practices:

However, acknowledgement could not be obtained because:

SLIDING FEE SCALE ELIGIBILITY DOCUMENTATION
 Yes     No

Discounted fees are available for individuals or families whose household income falls within o% and 200% of the federal poverty guidelines. If you are interested in applying for discounted services, you will need to provide information about your family and your income so your eligibility can be determined.

Family Size (includes all family members living within the household):

In order to qualify for PCHS' Sliding Fee Discount Program, you need to bring at least one document from the following list. The proof of income must be returned within 30 days of application. If you do not provide your proof of income by the due date, you will have to pay full price for services. The Sliding Fee Discount Program begins on the date your proof of income is received at the clinic. If you do not have any of this documentation, PCHS staff can assist you with self-declaring your income.

Income Validation Document Income Amount Copies Provided
Employment Wages and Earnings Paystub from work (last 30 days)
Self-Employed wage documentation(for last 3 months)
Most current Tax Return
Workers Compensation Statement/Stub
Military leave and earnings Statement/Stub
Employer income statement letter
Patient income statement letter
Benefits Disablility Income Statement/Stub
Current Social Security Statement/Stub
Unemployment Statement/Stub
Other Income Statement of chid support
Most Current Retirement Benefit Statement
Most Current Bank Statement
Other:
Total

Insurance Verification

 
 
Signature DATE & IP ADDRESS
For Office Use Only:
Patient Dental History
 
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No

AUTHORIZATION AND RELEASE

I CERTIFY THAT I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION TO THE BEST OF MY KNOWLEDGE. THE ABOVE QUESTIONS HAVE BEEN ACCURATELY ANSWERED. I UNDERSTAND THAT PROVIDING INCORRECT INFORMATION CAN BE DANGEROUS TO MY HEALTH. I AUTHORIZE THE DENTIST TO RELEASE ANY INFORMATION INCLUDING DIAGNOSIS AND THE RECORDS OF ANY TREATMENT OR EXAMINATION RENDERED TO ME OR MY CHILD DURING THE PERIOD OF SUCH DENTAL CARE TO THIRD PARTY PAYORS AND/OR HEALTH PRACTITIONERS. I AUTHORIZE AND REQUEST MY INSURANCE COMPANY TO PAY DIRECTLY TO THE DENTIST OR DENTAL GROUP INSURANCE BENEFITS OTHERWISE PAYABLE TO ME. I UNDERSTAND THAT MY DENTAL INSURANCE CARRIER MAY PAY LESS THAN THE ACTUAL BILL FOR SERVICES. I AGREE TO BE RESPONSIBLE FOR PAYMENT TO ALL SERVICES RENDERED ON MY BEHALF OR MY DEPENDENTS.

 
 
SIGNATURE OF PATIENT OR PARENT/GUARDIAN IF MINOR: DATE & IP ADDRESS
 
 
DOCTOR'S Signature DATE & IP ADDRESS
Patient Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is part of your body. Health problems that you may have, or medication that you may be taking, could have an important inter-relationship with the care you will receive. Thank you for answering the following questions.

 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Yes     No
 Pregnant/trying to get pregnant  Taking oral contraceptives  Nursing
 Aspirin  Penicillin  Codaine  Acrylic  Metal  Latex  Local anesthetics  Other (if yes please explain)
Do you have or have you had and of the following? Please circle if YES
AIDS/HIV Positive Alzheimers disease Anaphylaxis
Anemia Angina Arthritis/Gout
Artificial Heart Valves Artificial Bones/Joints Asthma
Blood Disease Blood Transfusion Breathing Problems
Bruise Easily Cancer Chemotheropy
Chest Pain Cold sores / Fever blisters Congenital heart disorder
Convulsion Cortisone medicine Diabetes
Difficulty Breathing Drug Addiction Easily Winded
Emphysema Epilepsy or Seizures Excessive Bleeding
Excessive Thirst Fainting spells / Dizziness Frequent Cough
Frequent Diarrhea Frequent Headaches Genital Herpes
Glaucoma Hay Fever Heart Attack / Failure
Heart Murmer Heart Trouble / Desease Hemophilea
Hepatitis A Hepatitis B or C Herpes
High Blood Pressure High Cholesterol Hives or Rash
Hypoglycemia Irregular Heartbeat Kidney Problem
Leukemia Liver Disease Low Blood Pressure
Lung diseases Mitral Value prolapse Osteoporosis
Pain in Jaw Joints Parathyroid Disease Psychiatric Care
Radiation Treatments Recent Weight Loss Renal Dialysis
Rheumatic Fever Rheumatism Scarlet Fever
Shingles Sickle Cell Disease Sinus Trouble
Spina Bifida Stomach/Intestinal Disease Stroke
Swelling of Limbs Thyroid Disease Tonsillitis
Tuberculosis Tumors or Growths Ulcers
Venereal Disease Yellow Jaundice
Have you ever had serious illnesses not listed?
Yes
No
Yes No
Yes No

To the best of my knowledge, the questions on this form have been acurately answered. I understand that providing incorrect information can be dangerous to my (or my patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

 
 
SIGNATURE OF PATIENT, PARENT OR GUARDIAN: DATE & IP ADDRESS
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