New Patient Forms – Cheung Dental Milpitas

Step 1 of 7

Date(Required)

SS/HIC/Patient ID#

Patients Name(Required)

First Last

Patients SS#(Required)

Patients Address(Required)

Street Address City State / Province / Region ZIP / Postal Code

Patients Sex(Required)

Male

Female

Patients Birthday

Patients Age(Required)

Patients Phone(Required)

Patients Email(Required)

Patients Occupation

Patient Employer/School

Marital Status

Employer/School Phone

Employer/School Address

Street Address City State / Province / Region ZIP / Postal Code

Spouse’s Name

First Last

Spouse's SS#

Spouse’s Birthday

Spouse's Employer

Whom may we thank for referring you?

Signatures

Insurance Assignment: I certify that I, and/or my dependent(s), have Insurance coverage with

Name of Insurance Company(ies)

and assign directly to Name of Insurance Company(ies) Dr.

all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all Charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named doctor may use my health care information and may disclose such information to the above-named insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Authorization to Release Protected Health Information: I understand that there may be a need to consult with other health care providers. I voluntarily authorize Dr.(Required)

Name of Doctor Disclosing PHI

to use and/or disclose my Protected Health Information (PHI) related to(Required)

Describe in detail the Protected Health Information you are authorizing to be used and/or disclosed

The information will be used and/or disclosed for the purpose of(Required)

Describe in d each purpose for which you are authorizing your Protected Health Information to used and/or disclosed.

I authorize Dr.(Required)

Name of Doctor Receiving PHI to receive and use the information. This authorization will end when my current treatment plan is completed or one year from the date signed below. I understand that once the information is released it may be redisclosed by the recipient and may no longer be protected by federal privacy regulations, I understand that I may revoke this authorization at any time by notifying. In writing, the above-named doctor disclosing the PHI. However, if I do revoke this authorization, it will not have any effect on any actions taken by the above-named doctor disclosing the PHI prior to their receipt of the revocation. I understand that my treatment cannot be conditioned on whether I sign this authorization. I understand I may refuse to sign this authorization.

Signature(Required)

Date(Required)

Please print name of Patient, Parent, Guardian or Personal Representative(Required)

Doctor’s Comments and update

Relationship to Patient(Required)

Signature(Required)

Date(Required)

CAPTCHA

302 Barber Ct, Milpitas, CA 95035

NOW CLOSED

Please Visit Our Cadillac Court Location

1112 Cadillac Court, Milpitas CA. 95035

Schedule Your Appointment 408-586-8847

New Patient Forms • Patient Registration

Please Click The Links Below To Fill Out And Sign Your Forms Online.

New Patient Form Packet

Dental Insurance

Phone Numbers

Dental History

Medical History

Medications

Signatures

302 Barber Ct, Milpitas, CA 95035

NOW CLOSED

Please Visit Our Cadillac Court Location​

1112 Cadillac Court, Milpitas CA. 95035

Schedule Your Appointment 408-586-8847

New Patient Forms • Patient Registration

Please Click The Links Below To Fill Out And Sign Your Forms Online.

New Patient Form Packet

Dental Insurance

Phone Numbers

Dental History

Medical History

Medications

Signatures

Please Visit Our Cadillac Court Location