New Patient Medical History

"*" indicates required fields

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First Name*
Middle Name
Last Name
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Have you ever had any of the following? Please check those that apply: *
Have you ever had an adverse reaction or allergies to any medication or substance? (Please check if allergic) *
Are you currently taking any medications? *

Have you ever been advised that you require antibiotics prior to a dental appointment? *

Are you currently under the care of a physician?

Are you taking any medication for Osteoporosis? (I.e. Bonviva, Fosamax, etc.)

Are you currently pregnant?

Are you currently taking any oral contraceptives?

Do you have any health problems that need further clarification?


Whom should we thank for referring you to our practice? *


The following is for:
First Name
Last Name
Is the following,


The following is for:


(If you do not have dental insurance, disregard the following questions and move to "Consent for Procedure" section.)
Is insured an AbadinDental patient?
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Patient's relationship to insured:


  1. Before treatment can be rendered, adequate radiographs must be taken. 
  2. Unless otherwise arranged, payment for professional service is required on the day the treatment is rendered. With prior approval, on certain extended procedures and treatment, payment plans can be arranged. 
  3. In order to avoid a possible missed appointment fee, we respectfully request a 48 hour notice to change your appointment. 
    • Please call during our regular business hours. 

This is to certify that I, the undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of the local anesthetic as indicated. I also certify that I have read and understand the above. Any questions that I may have regarding this form have been answered to my satisfaction. I will not hold the office of Jose R. Abadin, D.D.S. responsible for any errors of omissions that I have made in the completion of this form. 

I/We hereby guarantee payment of any and all bills rendered for said patient which are not covered or allowable by insurance, together with all collection costs, including a reasonable attorney's fee for legal counsel in the event that it becomes necessary for Jose R. Abadin, D.D.S. to file suit to effect payment. I understand that all bills are due and payable upon presentation. 

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 This notice is required by the new patient privacy regualtions by the United States Department of Health and Human Services (HHS). and describes how your medical information may be used or disclosed, and how you may gain access to your medical information. 

Your protected medical information (i.e., individually identifiable information, such as names, dates, phone/fax numbers, email, addresses and demographic date) may be used or disclosed by us in one or more of the following respects:

  • To other healthcare providers (i.e., your general dentist, oral surgeon, etc.) in connection with our rendering orthodontic treatment to you;
  • To Third Party payers or spouses (i.e., insurance companies, employers, with direct reimbursement, administrators of flexible spending accounts, etc.) in order to obtain payment of your account;
  • To certifing, licensing, and accrediting bodies (i.e., the American Board of Orthodontics, state dental boards, etc.) in connection with obtaining certification, licensure or accreditation; 
  • Internally, t all staff members who have any role in your treatment; and/or 
  • To other patients and third parties who may overhear conversations about your treatment, scheduling, etc. 

Under new privacy rules, you have the right to:

  • Request retrictions on the use and disclosure of your protected health information;
  • Request confidential communication of your protected health information;
  • Inspect and obtain copies of your protected health information through asking us; 
  • Amend or modify your protected health information; 
  • Receive an accounting of certain disclosure made by us of your protected health information;and, 
  • You may file a complaint with the HHS Secretary as to any violation by us of your privacy rights, which must be filed wihtin 180 days of the violation. 

We have the following duties under the privacy rules:

  • To only utilize your protected health information as set forth in the attached Consent Form and/or Authorization Form; 
  • To obtain your written consent to use your protected patient information for any purpose other than treatment, payment of health care operation;  
  • To use reasonable efforts to limit the amount of protected health information for any purpose other than treatment, payment of health care operation;
  • To use reasonable efforts to limit the amount of protected health information that is used, disclosed, or requested for purposes other than treatment; and, 
  • To obtain satisfactory assurances from our business associates who render services to our offices that your protected health information will be safeguarded by them. 

Please note that we are not obligated to:

  • Honor any request by you to restrict the use or disclosure of your protected health information;
  • Amend your protected health information if, for example, it is accurate and complete, or, 
  • Provide an atmosphere that is totally free of the possibility that your protected health information may be overheard by other patients and third parties. 

If you have any questions about the information in this Notice, please let us know. Thank you. 


You may refuse to sign this Acknowledgement
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Thank you!
If you have any questions about this form, please feel free to ask.