NORTHEAST MISS看SSIPPI HEALTH CARE, lNC.

PATIENT RたGISTRAT10N FORM

Patient

しast Name

Address (Street, Citv, State, Zip, County〉

First Name

CHART #

MI

Areyou ofしatino/Hispanic Descent? ( )YES ( 〉 NO

Date of B而h

Sociai Security #

Home Phone

Provider of Choice?

Preferred Language ( ) ENGLISH ( ) SPANISH

Special Communication Needs?

Ema=

Ce= Phone

MARITAしSTATUS:　　　　□ Singie　　　□ Married　　　　ロWidowed　　　　口Divorced

ETHNIC晴Y:(CheckailthatappIy)　口Asian　　口NativeAmerican　口White　口Hispanic/しatino

口Black/AfricanAmerican　　　　　口AmericanIndian/AlaskaNative

□OtherPacificIslander　　　　　　　口Morethanonerace

lNCASEOFEMERGENCY,WHOSHOUしDBENOTiFiED?

NAME　　　　　　　　　　　　　　　　　　　　　　　　NAME

REしA丁IONSHIP　　　　　　　　　　　　　　　　　　　　RELATIONSHIP

pHONE#　　　　　　　　　　　　　　　　　　　　　　　PHONE#

AUTHORIZATION FOR HEA町H CARE

l. 1 give permission to the Medica- Denta- Providers at NEMHC′ inc. to render care to me orthose forwhom l am

responsible as the P「ovider advises as necessary in the case of any emergency.

2. 1 hereby authorize NEMHC′血・ tO furnish such professiona冊ormation as necessary f「om my medicaI or dental

records compi-ed by NEMHC′ lnc.′ inc-uding professiona- services′ and hereby release NEMHC′ lnc. from aIi

liab冊y that may arise from the release ofthe information requested.

3. I/we agree to ACCEPT COMPLETE RESPONSIBILITY for a-1 charges based on ab冊y to pay and agree to pay the

same at the time services are rendered or no -ater than 90 days from the date of service o「 according to specified

payment (non-COVered Medicare′ Medicaid′ Private insurance charges). 1n the event of default l agree to pay aii

costs of co=ection, including reasonable attomey fees.

4. 1 agree that I have read and understand the above consent and w川accept its terms・

SIGNATURE OF PATiENT/RESPONS旧しE PARTY

1

PATIENT REGISTRATION FORM PAGE 2

DoyoucurrentlvhaveandAdvancedDirectiveorしivingW冊　　　YESロ　　　　NO□

DovouhaveaMedicalPowerofAttomey?　　　　　　　　　YES□　　　　NO□

Wouidbeinterestedintalkingtosomeoneaboutoneofthese?　　YES口　　　　NO　口

AreyouaVeteran?　　　　　　　　　　　　　　　　　　　YES口　　　　NO口

Doyou　　　　口iiveonyourown　　　　　　□Iivewithparents　　　口Other

A「eyouhomeIess?　　　　　　　　　　　YES口　　NO□

Doyou「esideinPubIichousing(Section8)?　YES□　　NO口

Since NEMHC, inc. is a Federally Qua嗣ed Heaith Center, We are requi「ed to col○ect this information for FederaI

reporting purposes.

pし各AS各 CH日CK oN日 �SEXUAしORIENTATION �PしたAS各 C軸且CK ONさ �GENDERIDENTITY

STRAiGHT/H打EROSEXUAL � �MAし各

GAY/LESBIAN/HOMOSEXUAL � �FEMAしE

BISEXUAし � �FEMAしETOMALETRANSGENDER

CHOOSENOTTODISCLOSE � �MALETOFEMALETRANSGENDER

DON′TKNOW � �CHOOSENOTTODISCしOSE

OTHER-PLEASESPECIFY � �

EMPしOYMENT INFORMATION

Patient’s EmpIoyer

EmpIoyer Phone ♯

1NSURANCE INFORMATION

DOYOUHAVEMEDICALINSURANCE?　口YES　口NO

PRIMARY INSURER:

NAME OF INSURED:

lD NUMBER:

GROUP ♯:

MEDICARE ♯:

MEDiCAiD ♯:

Empioyer Address

Posjtion:

SECONDARY INSURER

NAME OF INSURED:

ID NUMBER:

GROUP韓:

PARTAONしY口　　PARTB　□　　PARTD口

器器葦器嵩諾器謹書書誌誓書黒結盟柴。。-a- S。叫Administration, the Medicaid Commission′ the Centers for Medicare and Medicaid′ Or any Other third partv payor′ Or

their intermediaries, Or Carriers, needed forthis or a related claim・ l permit a copy ofthis authorization to be used in

place ofthe original′ and request payment of medical claims be made to this clinic"

2

ASSiGNMENT AUTHORIZATION §lGNATURE

PATIENT NAME

lVIEDIcAL HISTORY

AIthough dental personnei prlmarty t'eat the anea in and around your mouth- yOu「 mOuth is a part of you「 entire body. Heam叩bIems that you may

have・ Or medica(ion tha( you may be taking・ ∞uId have an impomnt inter胸ationship with the dentist「y you wilI re∞ive・ Thank you fo「 answering the

fo"owing questions,

Are you under a physicIan-s caro now?

Have you ever been hospitaIized or had a major opemtion?

Have you ever had a serious head o「 nec injury?

Are you faking any medications, PiiIs, O「 d田gS?

Do you take, Or have you taken, Phen-Fen or Redux?

Have岩盤霊言語罵轟詳器労O

Are you on a speclaI die(? ODo you use tobac∞? O

Do you u§e ∞ntroIled substan∞S? ○

If yes. please explain:

If yes, Please exかain:

PregnantITrying to get pregnant?O Yes O No T8king oraI ∞ntra∞Ptives?O Yes O No Nursing? O YesO No

Are you alIergic to any o( the fctIowing?

口Aspirin　口PeniciIiin　□codeine　□」ocaIAnesthetics　　　口AcryIic　□Mefal　口しatex　口Su胎dngs

口Other tryes, Please explaln:

Do you have, Or have you hadi any oI the foiIowing?

AIDS/HIV Positive O Yes O NoAkheimer’s Disease O Yes O No

AmphylaxIS O Yes O NoAncmia O Yes O NoAngina O Yes O NoArthritis/Goul O Yes O NoA請ficial Heart Vaive O Yes O No

ArtificiaI Joint O Yes O NoAsthma O Yes O NoBIood Disease O Yes O No馴ood T調nsfl」Sion O Yes O No

Broathin9 Probk)m O Yes O NoBnJiso EasiIy O Yes O NoCan∞l O Yes O No

Chemotherapy O Yes O NoChest Pains O Ye5 0 NoCold Soros/Fev○○ Blisl○○s O Yes O No

COnge面tal Heart Disorde○○ Yes O No

ConvuIsions O Yes O No

Cortisone Medicine O Yos O NoDiabol∞　　　　　O Yes O No

DnJ9Addic的n O Yes O No

EasilyWindod O Yes O NoEmphyse請a O Yes O No

EpitopsyorSeizuns O Yes O NoExcoesive B劇高調　　O Yes O No

Ex∞SSive Thi鴫t O Yes O No

F8intho SpoIIs/Dizz面essO Yes O No

Froquent Cough O Yes O NoFroquent Dia巾1Oa O Ye8 0 No

Froquen…cadaches O Yes O No

GenitalH叩es O Yes O No

GIau∞ma O Yes O No

Hay Feve「　　　　O Yes O No

Heart Attack作ailuro O Yes O No

Hearl Mumu○　　　○ Yes O No

H∞rl Pさ∞mのke「　O Yes O No

He8rt TroubIeIDiseaco O Yes O No

Have you ever had any serious illness not listed al)oVe?O Yes O No

Hemop刷ia

Hepa償is A

Hep8償is B or C

H○○pes

Hieh BIood Proesu鳩

HゆChok)S(erOI

Hives oI Rash

H押o9りcemia

I○○eguかHeartboal

櫛dney P∞b鴫同e

Leukemia

しiver Disease

Low Bk)Od P富essure

Lung DIsease

Mi(調i Vaive Prolapse

°s(eopo職場is

Pain in Jaw Joints

P8剛hy両d Disease

Psychiatric Caro

Radiation Treaments

Re∞n! WeiehtしOSS

ReIlal Dialysis

Rheumatic Fever

Rheumatism

Sca巾ot Fev○○

Tothebestofmyknowledge.thequestionsonthisfomhavebeena∞uratelyanswered.1unde「Standthatprovidingincorrectinfomationcanbe

dangeroustomy(0「Patient’§)heam.旧SmyreSpOnS酬ftyt面青くOmthedentaIo簡∞ofanychangesinmedicaistatus.

SiGNATUR∈OFPATIENT,PARENT,O「GUARDIAN　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　　DATE

〇〇〇〇〇

NoNoNoNoNo No NoNoNo

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YeS海S汚SYeS海S准S　汚S汚SYeS

博冊N。N。N。N。N。N。N。N。N。N。N。N。N。的N。NoN。

○○〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇

滴洛深海篭深海s悔汚s汚S窪Y・SYeS‰

〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇○○

N。的N。時N。N。N。N。N。N。N。N。N。N。的N。N。N 。No的

〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇〇○○

庵悔沈S性。汚S汚S汚。YeSYeS汚S悔順庵庵治悔悔YeSY・S

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