bhperiodontist logo416 N. Bedford Dr. Suite 209
Beverly Hills, CA 90210
Phone: (310) 275 - 4606
Fax: (310) 623 - 9106

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New Patient Form



Beverly Hills Periodontics & Dental Implant Center
Peiman Soleymani DDS
Diplomate of American Board of Periodontology

We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. If you have questions we’ll be glad to help you .We look forward to working with you in maintaining your dental health.

PATIENT INFORMATION



Name:
Last Name:

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First Name:

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Initials

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SS#

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Birth date:

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Male/Female:

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Address:
Street

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City

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Zip

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Phone Number:
Home No:

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Cell No:

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Office No:

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Email Address:

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Marital Status:

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Age:

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Drivers License/CAL ID:

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Employer:

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Occupation/Position:

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Office Address:

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Person to Contact in Case of Emergency:

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Phone No:

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whom May We Thank for Referring You

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PRIMARY INSURANCE


Name of Insurance Plan:

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Group No:

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Person Responsible for Account:

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SS#:

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Relation to Patient:

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Birth date:

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Insured Employer

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Bus. Phone No:

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Do you have Secondray Insurance?

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Name of Insurance Plan:

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Name of Former Dentist:

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Phone No:

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Date of Last Dental Care:

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Date of Last X-Rays:

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How often do you brush?

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Floss:

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How do you feel about appearance of your teeth?

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How may we serve you today?

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Kindly Check if you have had any of the following:



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MEDICAL HISTORY


Are you currently under a physician's care?

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for what condition:

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Dr.'s Name:

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Dr.'s Phone No.

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Have you had any serious illness or operation

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if yes, please describe:

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Have you ever had blood transfusion

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if yes, approximately when?

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For women: Are you pregnant?

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Nursing?

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Taking Birth Control Pills?

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Please Check if you have had any of the following:



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List Any Medications You are Currently Taking

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Allergies, if Any

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AUTHORIZATION



I have reviewed the information on this questioner,and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate and healthful dental treatment. If there are any changes to my medical status,I will inform the dentist.

I authorize the insurance company indicated on this form to pay to the dentist all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment whether or not paid by insurance. I understand that I am responsible for all charges incurred whether or not paid by insurance.



Signature

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Date:

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Doctor's Signature

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Date:

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I have been given the copy of notice of HEALTH INSURANCE PORTABILITY and ACCOUNTABILITY ACT of 1996(HIPAA).

Signature

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Date:

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Please enter the text shown in the image

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