Submit Your Health History Form Online to Your Dentist at Lasting Smiles Dental Care

Save time at the doctor's office and fill out your registration and health history information online! Take a few minutes to fill out this confidential form, click the "Submit Form" button at the bottom, and your information will be sent to our office with secure encryption. We will already have your information when you arrive for your first appointment. You may need to provide a signature at the office to verify that the information you submitted online is accurate.

Patient Information

Items marked with asterisk (*) must be completed.

Date

First Name*

Please fill in this field

Middle Name

Last Name*

Please fill in this field

I prefer to be called (Nickname)

Birth Date (MM-DD-YYYY)*

Please enter a valid date

Social Security Number (U.S. only)

Home Phone*

Please enter a valid phone number

Address*

Street

City

State/Province

Zip/Postal Code

Country

Work Phone

Cell/Other Phone*

Please enter a valid phone number

Email Address

Gender*

Male

Female

Please select a gender

If patient is a minor, give parent's or guardian's name

Whom may we thank for referring you to our office?*

Please fill in this field

Responsible Party Information

Who is responsible?

Self

Someone Else

Full Name

Mailing Address (if different)

Street

City

State/Province

Zip/Postal Code

Country

Home Phone

Please enter a valid phone number

Work Phone

Cell/Other Phone

Email Address

Social Security Number (U.S. only)

Birth Date (MM-DD-YYYY)

Relationship to Patient

Employer

Occupation

Dental Insurance Information

Do you have Dental Insurance?

Yes

Insured's Name

Social Security Number (U.S. only)

Insurance Company

Group Number

Local Number

Phone Number

Do you have dual coverage?

Yes

This field is required.

Emergency Information

Person to contact in case of emergency

Complete Address

Street

City

State/Province

Zip/Postal Code

Country

Phone

Medical History

ALTHOUGH DENTAL PERSONNEL PRIMARILY TREAT THE AREA IN AND AROUND YOUR MOUTH, YOUR MOUTH IS A PART OF YOUR ENTIRE BODY. HEALTH PROBLEMS THAT YOU MAY HAVE, OR MEDICATION THAT YOU MAY BE TAKING, COULD HAVE AN IMPORTANT INTERRELATIONSHIP WITH THE DENTISTRY THAT YOU WILL BE RECEIVING. THANK YOU FOR ANSWERING THE FOLLOWING QUESTIONS.

ARE YOU ALLERGIC TO OR HAVE YOU HAD REACTIONS TO ANY OF THE FOLLOWING

Local Anesthetics like Novocain

Penicillin or Other Antibiotics

Sulfa Drugs

Barbiturates, Sedatives or Sleeping Pills

Aspirin

Iodine

Any Metals (E.G., Nickel, Mercury, Etc.)

Latex/Rubber

Other (Please List)

PLEASE CHECK ANY OF THE FOLLOWING THAT YOU HAVE HAD OR CURRENTLY HAVE:

Abnormal bleeding/Hemophilia

Anemia

Arthritis

Asthma or Hay fever

Congenital Heart Defect

Diabetes

Fainting or Dizzy Spells

Epilepsy or Seizures

Heart Problems

Heart Murmur

Hepatitis/Liver Problems

Herpes

High/Low Blood Pressure

HIV/Aids

Kidney Problems

High Cholesterol

Pneumonia

Nervous Disorders

Radiation/Chemotherapy

Rheumatic Fever

Tuberculosis

Tumor or Cancer

Scarlet Fever

Chest Pain

Shortness of Breath

Pacemaker

Heart Surgery

Swelling of Feet, Ankles, Hands

Stroke

Sinus Trouble

Lung or Breathing Problems

Hives or Skin Rash

Thyroid Problems

Allergies

Joint Replacement or Implant

Stomach ulcer

Persistant Cough

Sexually Transmitted Disease

Glaucoma

Tonsillitis

Mental Health Care

Back Problems

Chemical Dependency

Mitral Valve Prolapse

Cortisone Treatment

Cold Sores/ Fever Blisters

Hypoglycemia

Eating Disorders

1. Are you in good health

2. Have there been any changes in your general health within the past year

3. Date of your last physical exam

4. Physician's name, address and phone #

5. Are you now under the care of a physician?

Yes

6. Have you ever been hospitalized for any surgical operation or serious illness? If yes, please explain

7. Are you taking any medicines including non-prescription medicine? If yes, please list them

Pharmacy used?

Full Name*

Please fill in this field

Phone*

Please enter a valid phone number

Street*

City*

State/Province*

Zip/Postal Code*

Country*

8. Have you had any abnormal bleeding?

Yes

9. Do you bruise easliy?

Yes

10. Have you ever required a blood tranfusion?

Yes

11. Have you had a recent weight loss?

Yes

13. Have you ever taken Fosamax, Boniva, Actonel or any cancer medications?

Yes

14. Have you ever Viagra, Revatio. Cialis or Levitra in the last 24 hours?

Yes

15. Do you use tobacco?

Yes

16. Do you or have you used controlled substances?

Yes

17. Are you wearing contact lenses?

Yes

18. Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks?)

Yes

19. Do you have any disease, condition or problem not listed above that you think we should know about.

WOMEN, please answer the below questions

Are you pregnant or think you may be pregnant?

Yes

How Many Weeks?

Are you nursing?

Yes

Are you taking birth control pills?

Yes

Dental History

General Dentist

Date of Last Visit

When?

Do your gums bleed while brushing or flossing?

Yes

Are your teeth sensitive to hot or cold liquids/ foods?

Yes

Are your teeth sensitive to sweet or sour liquids/ food?

Yes

Do you feel pain to any of your teeth?

Yes

Do you have any sores or lumps in or near your mouth?

Yes

Have you had any head, neck or jaw injuries?

Yes

Have you ever experienced any of the following problems in your jaw

Clicking

Yes

Pain (joint, ear, side of face)

Yes

Difficulty in opening or closing

Yes

Difficulty in chewing

Yes

Do you have frequent headaches?

Yes

Do you clench or grind your teeth?

Yes

Do you bite your lips or cheeks frequently?

Yes

Does food tend to become caught between your teeth?

Yes

Have you ever had periodontal treatment (gums)?

Yes

Have you ever had any difficult extractions in the past?

Yes

Ever worn a bite plate or other appliance?

Yes

Have you ever had any prolonged bleeding following extractions?

Yes

Do you wear dentures or partials? If yes, date of placement

Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

Yes

If you could change ANYTHING about your smile, what would you change?

Reason for your visit with us

Have you had a complete series of dental films (x-rays) taken? If yes, When and where?

How often do you brush your teeth?

How often do you floss your teeth?

Is your drinking water fluoridated?

Yes

Do you snore at night?

Yes

Have you ever been diagnosed with sleep apnea? If yes, do you use a CPAP machine?

Yes

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 the diagnosis and the records of any treatment or examination rendered to me 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 of all services rendered on my behalf or my dependents. By clicking the "Submit Form" button below, you certify that the above information is correct and accurate to the best of your knowledge. All information is confidential and is accessed only via a secure, encrypted interface.

I agree and understand that by signing the Electronic Signature Acknowledgment and Consent Form, that all electronic signatures are the legal equivalent of my manual/handwritten signature and I consent to be legally bound to this agreement. I further agree my signature on this document is as valid as if I signed the document in writing. This is to be used in conjunction with the use of electronic signatures on all forms regarding any and all future documentation with a signature requirement, should I elect to have signed electronically. Under penalty of perjury, I herewith affirm that my electronic signature, and all future electronic signatures, were signed by myself with full knowledge and consent and am legally bound to these terms and conditions.

Please sign below additional required forms

HIPAA Consent Form

Click the link below to view our HIPAA Privacy Policy*

Consent For Treatment

Click the link below to view our Consent for Treatment*

Financial Policy Form

Click the link below to view our Financial Policy*

Office Policies

Click the below link to view our Office Policies*

194 N. Highway 27, Suite F, Clermont, FL 34711

CONSENT FOR USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

PURPOSE OF CONSENT: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities and healthcare operations.

NOTICE OF PRIVACY PRACTICES: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities and healthcare operations, of the uses and disclosures we may make of your protected health information and of other important matters about your protected health information. A copy of our Notice accompanies this consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

**We reserve the right to decline treatment if you refuse to sign this Consent.**

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting Shelli Worth (privacy officer) at 352-243-0018.

RIGHT TO REVOKE: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the contact person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation and that we may decline to treat you or to continue treating you if you revoke this Consent.

(print your name)
Please enter your name

, hereby authorize Lasting Smiles Dental Care and Nadim Haidar DDS LLC

(hereby collectively referred to as “Practice”) to use and disclose the entire medical record concerning

(print patient’s name)
Please enter patient’s name

. In accordance with the attached Notice of Privacy Practices (NOPP).

I have reviewed the NOPP, been given an opportunity to ask questions about it, understand it and do hereby agree to its terms. I understand that my records may be subject to re-disclosure by recipients and unprotected by federal or state law. A copy of this signed and dated Consent shall be as effective as the original. I release, hold harmless and agree to indemnify Practice, its employees and agents for any and all liability (including but not limited to negligence) arising out of or occurring under this consent.

/ Signature This field is required.

/ Print Name This field is required.

/ Relationship to Patient This field is required.

Date

194 N. Highway 27, Suite F, Clermont, FL 34711

CONSENT FOR TREATMENT

I hereby authorize the doctors and the designated staff of Lasting Smiles Dental Care to take X-rays, study models, photographs and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of
(Name of the patient) ‘s dental needs.
Please enter patient name
Upon such a diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed upon by me to employ such assistance as required to provide proper care.
I agree to use the anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understands that I can ask for complete recital of any possible complications.
I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service.

Patient’s Signature

This field is required.

Date

Parent/Responsible Party’s Signature

This field is required.

Relationship to Patient

This field is required.

FINANCIAL POLICY

We would like to welcome you to our office. Here at Lasting Smiles Dental Care we strive to provide you with excellent dental care and our goal is to make your visits as pleasurable as possible. Good communication concerning your dental needs, treatment procedures and fees is one of most important goals. We request payment for services at the time they are rendered. Payment for services may be made in any of the following ways: Cash, Check, Visa, Master Card, Discover, American Express or Care Credit.

By signing below you confirm that you have read this policy and understand that:

It is your responsibility to inform our office of any address or telephone number changes.
Your account is to be kept current - All self-pay, estimated payments and deductibles will be collected at the time of service.
A returned check will result in a $50 service charge and all future payments must be paid in cash or by credit card.

IF YOU HAVE DENTAL INSURANCE COVERAGE:

Please let us know in advance. We will submit your claims, however we must emphasize that as a dental provider, our relationship is with you, NOT your insurance company. Although we attempt to verify your dental benefits with your insurance company, please be advised this is only an ESTIMATE of your coverage based on the information given to us at the time of the inquiry.

By signing below you confirm that you understand:

It is your responsibility to inform us of any changes to your insurance policy so that your coverage can be re-verified before your appointment.
Not all services are a covered benefit with all insurance plans.
It is your responsibility to be aware of what services are being provided to you and if it is a covered benefit under your insurance policy.
If the claim is denied we may ask that you call on your own behalf. It is more likely that your insurance company will explain to you, since you are the policy holder and premium payer.
You are responsible for any non-covered charges not payable by your insurance.

Filing your insurance claims is a courtesy extended to you. ALL charges are ALWAYS YOUR RESPONSIBILITY from the date services are rendered.

If you need any assistance with applying to a Care Credit account, our staff will be happy to guide you through the process of application.

/ Patient Name (Print) This field is required.

/ Patient/Responsible Party Signature This field is required.

Date

194 N. U.S. Highway 27, Suite–F, Clermont, FL 34711

Welcome to Lasting Smiles Dental Care. We are a general dental practice that blends old-fashioned service and the latest technology with professionalism and a sense of humor. We are committed to providing dental care and the finest service possible for our patients. A healthy mouth is the gateway to a healthy body. Research has linked poor dental health to medical problems of the heart, lungs, blood vessels, gastrointestinal tract, diabetes and more. In addition to traditional preventive, restorative and cosmetic dentistry, we offer dental implants to restore missing teeth, pain-free Laser treatment and same-visit computer generated all porcelain restorations (CEREC). We are proud of our patient-centered philosophy and personalized care in this modern age of indifference, we focus on helping patients take responsibility for their oral health, on knowing each patient as an individual and on making dental visits pleasant, gentle and pain-free. Our goal is to educate our patients on the value of maintaining their natural teeth and their oral health so that they may enjoy the benefits and quality of life from a healthy, comfortable, functional and lasting smile.

OFFICE POLICIES

OFFICE HOURS – Monday to Friday 7:30am-5pm.

Hours are subject to change.

APPOINTMENTS – Dental treatment is a very personalized and time-intensive service and we reserve specific time in which to perform the procedures. When you schedule an appointment, it is your responsibility to keep that appointment. We will make an effort to contact you to remind you of your appointment, however, it is still your responsibility to show up whether you hear from us or not. If you have any questions, please call to verify. Please call at least 48 hours before your appointment and speak with a real person to cancel an appointment. If you are going to be late, please call us so we are aware of the situation. We understand that things happen, however, just as your time is valuable, our time is valuable. The charge for broken appointments with less than 48 hours notice is $50. (If a patient does not show up for an appointment for which we have reserved the time, the patient does not get the treatment needed and someone else does not get the treatment they may have needed). We accommodate emergencies for our patients of record within 24 hours. We try to accommodate all who truly want and need to be seen.

X-RAYS AND EXAMINATIONS – It is required by law that we establish a baseline and diagnosis of your oral health prior to prescribing a “cleaning” appointment or other treatment visit. X-rays and an examination help us formulate the blueprint for your care and proper sequencing. We also may need photographs and diagnostic models to help us study your particular dental issues and plan treatment.

MEDICAL HISTORY – Please be sure that you give us your complete medical history and inform us of any changes. It is your responsibility to inform us of any medical alerts or conditions and any prescribed and over the counter medications and any changes before every treatment.

CHILD VISITS – A parent needs to accompany minors under 18 years of age at the time of the appointment unless we have a written consent prior to the appointment that a relative or friend has authority.

FINANCIAL POLICY – Full payment is expected at the time service is rendered. We accept cash, checks, Visa, Master Card, Discover, American Express and Care Credit. Returned checks will be charged a $50 service fee.

I have read, had the opportunity to ask questions and understand the office policy.

Patient Signature:

This field is required.

Date:

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