New Patient Registration

Leeward Pediatric Dentistry, LLC
94-229 Waipahu Depot St
Ste. 501, Waipahu HI 96797
(808)671-0055
admin@leewardpediatricdentistry.com
Welcome to Leeward Pediatric Dentistry, to better serve you please fill in the following information completely:
Patient Name*
First Middle Last
Preferred Name
Gender*
- Male
- Female
Family Status*
- Married
- Single
- Child
- Other
Birth Date*
Previous Visit
Email Address
Phone(Home)
Phone(Work)
Mobile*
Best time to call
Address*
Street Address Address Line 2 City State ZIP Code
Medicaid/Quest patients please complete the following:
Subscriber's Name
Subscriber's ID#

Mother/Legal Guardian Information *
Mother's Name*
Date of Birth*
Social Security Number
Email Address*
Occupation and Employer
Primary Contact Phone Number*
Secondary Contact Phone Number
Business Phone
Is your child covered under your dental plan?*
- Yes
- No
If yes, Name of Dental Insurance:*
Policy ID Number*
Group Number*

Father/Legal Guardian Information *
Father's Name*
Date of Birth*
Social Security Number
Email Address*
Occupation and Employer
Primary Contact Phone Number*
Secondary Contact Phone Number
Business Phone
Is your child covered under your dental plan?*
- Yes
- No
If yes, Name of Dental Insurance:*
Policy ID Number*
Group Number*
Does Mother, Father and Child all live together?
- Yes
- No
Name of closest relative not living in the same house as patient
Relationship
Phone Number

Office Mission Statement

Our happy and passionate team is committed to delivering outstanding dental care for your child. We believe in educating you and your child about the importance of dental health and encouraging your child to practice optimal dental health habits.
Appointment Policy

We understand that circumstances and unscheduled events arise creating the need to cancel or re-schedule appointments.
Therefore, we kindly ask that you inform us within 48 hours if you are unable to keep your scheduled appointment so that we may contact another patient who is in need of dental care.

In the event of a late cancellation or no-show (appointments that are cancelled less than 48 hours) a $50 fee may be assessed.

To prevent this fee from being charged, our office requires that all appointments be re-confirmed within 24 hours of the appointment time or it will be removed from our schedule.
Treatment Consent*
After explanation by the doctor, I hereby authorize the performance of dental services upon the above named patients and whatever procedures that the judgment of the doctor may dictate in order to carry out these procedures.
I understand that my child will come in by themself for treatment.
I understand that if my child may danger themself or anyone in the restorative process, a clinical assistant will hold their hands for safety purposes.
I also understand that if they are very uncooperative, the Doctor may be firm with them and use voice control to manage them.
I authorize and request the administration of any anesthetics and x-rays which may be deemed necessary and advisable by the doctor.
I agree to the treatment consent policy.
Signature
Date: 10/29/2025

Financial Policy*
This office depends upon reimbursement from the patient for the costs incurred in their care. The financial responsibility of each patient must be determined before treatment. As a condition of treatment by this office, I understand financial
arrangements must be made in advance. All dental service performed without prior financial arrangements, must be paid for at the time services are performed. I understand that dental services furnished to me are charged directly to me and that I am personally responsible for payment. If I carry insurance, I understand that this office will help prepare my insurance forms to assist in making collections from insurance companies and will credit such collections to my account. However, this dental office cannot render services on the assumption that charges will be paid by an insurance company.

Assignment of Insurance: I hereby authorize release of any information needed and also authorize my insurance company to pay directly to This Office benefits accruing to me under my policy. I understand that the fee estimate listed for this dental care can only be extended for a period of 90 days from the date of the patients examination. I also understand that in order to collect my debt, my credit history may be checked through the use of my Social Security Number or any other information I have given you. I agree that in the event that either this office or I institute any legal proceedings with respect to amounts owed by me for services rendered, the prevailing party in such proceeding shall be entitled to recover all costs incurred including reasonable attorneys fees. I grant my permission to you, or your assigns, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions and agree to their content.

To the best of my knowledge, I have answered every question completely and accurately. I will inform the dentist of any change in my child's health, medication and/or dental needs.
I agree to the Financial Policy
Signature
Date: 10/29/2025

NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
Consent
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 04/14/2003 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law.
We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices or for additional copies of this Notice please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of students, healthcare professionals, evaluating practitioner and provider performance conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friends or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect or domestic violence or the possible victim of any other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities, We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, letters or SMS text messages).

PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies we will charge you $10.00 for health information and no charge per hour for staff time to locate and copy our health information which will take up to 5 business days and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation or our fee structure).

Disclosure Accounting: you have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes other than treatment, payment, healthcare operations and certain other activities for the last 5 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional
requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing). Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us.
If you concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer: JAMES M. HORI, D.D.S
Telephone: (808) 671-0055
Address: 94-229 WAIPAHU DEPOT ST. STE. #501 WAIPAHU, HI 96797
I agree to the privacy policy.
Would you like to receive a copy of our HIPAA Form?
- Yes
- No
Signature
Date: 10/29/2025

NAME, IMAGE AND LIKENESS RELEASE
Consent
Dr. James Hori and Bryan Sato (hereinafter referred to as doctor) welcomes your participation and willingness to share photographs and images of yourself or stories about your experience with our practice for promotional and testimonial purposes on our practice website and social media outlets(collectively, the Project)

Each customer ("customer") who is photographed by or submits a photograph to Doctor with or without a story in connection with this Project hereby agrees to these terms:
1.) You Give Us Your Consent to Take Your Photograph and to Use Your Name and Photograph and/or Story. Customer consents to Doctor and those acting with their authority and permission, the absolute right and permission to photograph, film and record (in any medium) my name, biography, image, likeness, statements and performance (collectively, Image and Likeness), including the right to use the same worldwide in any and all media, in whole or in part, in perpetuity, for any lawful purpose whatsoever without restriction, including, without limitation, in and in connection with the Project and advertising and promotional of the Project.

2.) Customer further consents to the use of his/her name, likeness, photograph, quotation, comment, testimonial, and/or story (collectively, the "uses") by Doctor for advertising, trade and any other lawful purpose, together with the right to publish the same and/or copyright any materials that use them.

3. Customer also grands Doctor a non-exclusive, irrevocable, worldwide, royalty-free license to reproduce, distribute and publicly display his/her photograph, as well as customer's first name, last initial and hometown in promotions and other publications in any and all media, in any locale, in perpetuity, for any purpose whatsoever, without any compensation, provided it is understood that Doctor shall not utilize customer's submission in any way to intentionally and maliciously subject customer to conspicuous ridicule or indignity. Customer grants Doctor the right to edit his or her photograph and/or story.

4.) Customers will not be paid for granting Doctor any of the above rights.

Customer acknowledges that he or she owns all intellectual property rights that relate to his or her photograph and/or story, whether it is creating it or by getting a transfer from someone like the photographer.

6.) Customer also acknowledges that the submitted story is original and accurate, that the photograph for use with customer's first name, last initial, and hometown is of customer, and that the consent of any other people mentioned in the story or shown in the photograph(s) have also been obtained.
I agree to the privacy policy.
Signature of Patient or Legal Guardian
If patient is under 18 years of age, Signature of Legal Guardian is required.
Date: 10/29/2025
Comments
This field is for validation purposes and should be left unchanged.

Step 1 of 9 - Getting to know your child better

Medicaid/Quest patients please complete the following:

Mother/Legal Guardian Information *

Father/Legal Guardian Information *

Patient's Medical History

Patient's Dental Health

Office Mission Statement

Appointment Policy

NOTICE OF PRIVACY PRACTICES

NAME, IMAGE AND LIKENESS RELEASE