New Patient Registration Form | Dr. John Harman Dental Care

For your convenience, you can either download the PDF and fill out the form, or use the online form below and submit.



NOTE: * indicates required information.

    Patient Is:

    Responsible Party: (if someone other than the patient)

    Patient Information:

    Sex: Marital Status:

    Employment Status: Student Status:

    Primary Insurance Information:

    Please Check Box If You Don't Have Insurance
    Relationship Of Insured:

    Secondary Insurance Information:

    Please Check Box If You Don't Have Insurance
    Relationship Of Insured:

    John Harman IV, D.D.S.PLLC

    Eaglesoft 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 you will receive.

    Are you under a physician's care now?
    Have you ever been hospitalized or had a major operation?
    Have you ever had a serious head or neck injury?
    Are you taking any medications, pills, or drugs?
    Do you take, or have you taken, Phen-Fen or Redux?
    Have you ever taken Fosamax, Boniva,Actonel or any other medications contaning bisphosphonatest?
    Are you on a special diet?
    Do you use tobacco?

    Women: Are you...

    Are you allergic to any of the following?

    Do you use controlled substances?
    Do you have any dental concerns or discomfort in your mouth?
    Are you interested in Botox or Dermal Fillers?

    Do you have, or have you had, any of the following?

    AIDS/HIV Positive
    Alzheimer's Disease
    Artificial Heart Valve
    Artificial Joint
    Blood Disease
    Blood Transfusion
    Breathing Problems
    Bruise Easily
    Chest Pains
    Cold Sores/Fever Blisters
    Congenital Heart Disorder
    Yellow Jaundice

    Cortisone Medicine
    Drug Addiction
    Easily Winded
    Epilepsy or Seizures
    Excessive Bleeding
    Excessive Thirst
    Fainting Spells/Dizziness
    Frequent Cough
    Frequent Diarrhea
    Frequent Headaches
    Genital Herpes
    Hay Fever
    Heart Attack/Failure
    Heart Murmur
    Heart Pacemaker
    Heart Trouble/Disease

    Hepatitis A
    Hepatitis B or C
    High Blood Pressure
    High Cholesterol
    Hives or Rash
    Irregular Heartbeat
    Kidney Problems
    Liver Disease
    Low Blood Pressure
    Lung Disease
    Mitral Valve Prolapse
    Pain in Jaw Joints
    Parathyroid Disease
    Psychiatric Care

    Radiation Treatments
    Recent Weight Loss
    Renal Dialysis
    Rheumatic Fever
    Scarlet Fever
    Sickle Cell Disease
    Sinus Trouble
    Spina Bifida
    Swelling of Limbs
    Thyroid Disease
    Tumors or Growths
    Venereal Disease

    Have you ever had any serious illness not listed

    Effective date of notice:


    4730 E. Indian School Rd #210
    Phoenix, Az. 85018
    Phone: 602-840-5300 / Fax: 602-840-3401


    We respect our legal obligation to keep health information that identifies you private. We are obligated by Lawton give you notice of our privacy practices. This notice describes how we protect your health information and what rights you have regarding it.


    The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purpose are: setting up an appointment for you: examining your teeth; prescribing medications and faxing them to be filled; referring you to another doctor or clinic for other health care or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for the payment purpose are: asking you about your health or dental care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). “Health care operations” mean those administrative and managerial functions that we have to do in order to run our offices. Examples of how we use or disclose your health information for health car operations are: financial or billing audits; internal quality insurance; personal decisions; participations in managed care plans; defence of legal matters; business planning; and outside storage of our records.

    We routinely use your health information inside out office for these purpose without any special permission. If we need to disclose your health information outside of our office for these reasons, [we will] [we usually will not ask you for special written permissions.


    In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are:

    • when a state to federal law mandates that certain health information be reported for a specific purpose;

    • for public health purpose, such as contagious disease reporting, investigation or surveillance; and notice to and from the federal Food and Drug Administration regarding drugs or medical devices;

    • disclosures to government authorities about victims of suspected abuse, neglect or domestic violence;

    • uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by by Medicare or Medicaid; or for investigation of possible violations of health care laws;

    • disclosures for judicial and administrative proceedings, such as in response to subpoenas or order of courts or administrative agencies;

    • disclosures for law enforcement purpose, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else;

    • disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations;

    • uses or disclosures for health related research;

    • uses and disclosures to prevent a serious threat to health or safety;

    • uses and disclosures for specialized government functions, such as for the protections of the president or high ranking government officials; for lawful national intelligence activities; for military purpose; or for the evaluation and health of members of the foreign services;

    • disclosures of de-identified information;

    • disclosures relating to worker’s compensation programs;

    • disclosures of a “limited data set” for research, public health. or health care operations;

    • incidental disclosures that are an unavoidable by-product of permitted uses or disclosures;

    • disclosures to “business associates” who perform health care operations for us and who commit to respect the privacy of your health information;

    • [specify other uses and disclosures affected by state law].

    Unless you object, we will also share relevant information about you care with your family or friends who are helping you with your dental care.


    We may call or write to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also call or write to notify you of other treatments or services available at our offices that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave you reminder message on your home answering machine or with someone who answers your phone if you are not home.


    We will not make any other uses or disclosures of your health information unless you sign a written "authorization form." The contact of an "authorization form" is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it's your idea for us to send your information to some else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice.


    The law gives you many rights regarding your health information. You can:

    • ask us to restrict our uses and disclosures for purposes of treatment ( except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person at the address, fax or E Mail shown at the beginning of this Notice.

    • ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information to a different address, or by using E mail to your personal E Mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.

    • ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site). You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.

    • ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information. we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address, fax or E mail shown at the beginning of this Notice.

    • get a list of the disclosures that we have made of your health information within the past six years ( or a shorter period if you want). By law, the list will not include: disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. if you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice.

    • get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies, send a written request to the office contact person at the address, fax or E mail shown at the beginning if this Notice.


    By law, we must abide by terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any times as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Web site.


    If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S.Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone.


    If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice.


    I acknowledge that I received a copy of Dr. John N. Harman Notice of Privacy Practices.

    Dr. Harman Logo

    Financial Policy Dr. Harman Dental Care
    4730 E. Indian School Rd.
    Suite 210
    Phoenix, AZ 85018
    Phone: 602-840-5300 / Fax: 602-840-3401
    Thank you for choosing us as your dental care provider! We welcome you and your family and are committed to providing quality dental care to our patients.

    All patients/guarantors are responsible for payment at the time of service, unless prior arrangements have been made.

    Payment Methods: We accept cash, Visa, Mastercard, American Express, Care Credit, and Discover.

    Insurance: It is the patient's responsibility to know and understand your dental benefits. As a courtesy to our patients, we will submit a claim to your insurance carrier on your behalf. If for any reason your in insurance company pays less than estimated, or in the event they pay nothing, the patient is responsible for the unpaid fees.

    Deductible and Coinsurance: All deductible and coinsurance payments are due on the date services are rendered.

    Financing: We offer an interest free payment plan, through Care Credit, for up to 18 months (to those that qualify through Care Credit). If interested please ask our front office staff for more information.

    Collections: Any accounts more than 90 days delinquent will be turned over to a collection agency.

    Missed or Canceled Appointments: All reserved time with the dentist or hygienist requires a 48 hour (business day) notice to cancel or re-schedule. If this courtesy is not practiced a fee of $50.00 will apply.

    It's the patient's responsibility to notify our office if there is a change of name, insurance coverage, address, or phone number.

    I have read and agree to abide by this financial policy

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