Mina Narula DDS, MDS

71949 Hwy 111 Suite 200, Rancho Mirage, California, 92270

760-340-2026

Confidential Patient Information

Date
Patient Name:
Address
Phone
Birthdate
Social Security #
Email
Present dentist?
Date of last visit
School
Grade

Confidential Responsible Party Information

Name:
Marital Status:
Residence
Mailing Address
How long at this address
Home Phone
Cell Phone:
Work Phone
Previous Address
Email Address
Whom may we thank for referring you?
Social Security#
Birthdate
Employer
Occupation
No. Years Employed
Spouse's Name:
Relationship to Patient
Employer
Occupation
No. Years Employed
Social Security#
Birthdate

Insurance Information

Do you have orthodontic coverage?
Benefit amount

If no, please skip this section.

Insured's Name
Birthdate
Insured's Soc. Sec. #
Insured's Employer
Group No.
Local No.
Insurance Company Name and Address
Insurance Company Phone Number
Secondary insurance?
Benefit amount
Insured's Name
Birthdate
Insured's Soc. Sec. #
Insured's Employer
Group No.
Local No.
Insurance Company Name and Address
Insurance Company Phone Number

Emergency Information

Name of nearest relative not living with you
Complete Address
Phone
Relationship:
What is the reason for your visit today?

Authorization and Release

In accordance with HIPPA regulations, I hereby give my permission for the office of Dr. Mina Narula to use patient records and information for diagnosis, treatment planning, promotion, education, and insurance purposes.

I authorize the dentist to release any information including the diagnosis, and records for treatment rendered to me or my child if necessary for insurance purposes. I also authorize direct payment of insurance benefits to the dentist for services rendered when indicated.

I understand that where approriate, credit bureau reports may be obtained.

Signature (Parent's signature if minor)

Use your mouse cursor or the tip of your finger to sign below

Updates (date & initial)

Medical History

Nail Biting
Has your jaw ever clicked, popped or locked?
Is patient in good health?
Does patient have any history of major illness?
Has patient ever been under the care of a physician for illness?
If yes, give reason
Check any of the following for which the patient has been treated or diagnosed with:
Does patient take any bisphosphonate medications for osteoporosis, such as Fosamax?
Does patient have a tendency to colds?
Sore Throats?
Ear Infections?
Have tonsils and/or adenoids been removed?
At what age?
List any drugs or medications now being taken and give reasons
List any allergies or drug sensitivity
If physically disabled/ handicapped

Patient Questionnaire

Name:
Date:

Patients often request changes in their bite or face and relief from pain or discomfort. Please help us understand your problem by checking the following information. Please be specific (check the words backward, less, shorter, etc.)

Teeth: If your teeth could be changed, how would you like them to change?


Face: If your facial appearance could be changed, what would you change?


Symptoms: If you want to reduce pain or discomfort, where would it be located? Please be specific about the location; check the right side, left side, or both if they apply.


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