Patient Information
Are you under a physician's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you use controlled substances?
Women: Are you
Are you allergic to any of the following?
Do you have or have you had any of the following?
Have you had any serious illness not listed above?
*Condition may require medication

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

Acknowledgement of receipt of statement of privacy practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Edward P. Laco, DDS, PC. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

Edward P. Laco, DDS, PC reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

Additional Disclosure Authorization

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is "NO". Without indicating "YES" in answer to each individual question, protected health information (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

Spouse Only
Any member of my immediate family: (i.e. Spouse, Children, Siblings, etc.)
Any member of my extended family: (i.e. Parents, Grandchildren)
Other
Office use only below this line
Acknowledgement Not Obtained
Provided Prior to Treatment?
Reason for not obtaining patient signature