Date: ______________________Home: ____________________Cell: ______________________
PATIENT INFORMATION
Name: Last______________________ First_____________________________ Middle Initial____
SS/HIC/Patient ID# _________________________________
Address/City/State/Zip code: ________________________________________________________________________________
Email: _______________________________________________________
Sex: M/F______ Age: ______ Birthdate: _______________
Married/Single/Widowed/Divorced/Minor/Separated/Partnered ___________________
Patient Employer/School:_____________________________Ocuupation:_________________________
Employer/School Address: _____________________________________________________________________________________
Employer/School Phone Number: _____________________________
Whom May we thank for referring you? ____________________________________________________
In case of an emergency who may, we notify?
Name/Phone Number: _________________________ ________________________________________
PRIMARY INSURANCE
Person Responsible for your Account/Name: ________________________________________________
Relation to Patient: _______________Subscriber DOB:______________ Subscriber ID#/SS# ____________________
Address If different from Patient:_________________________________________________________Phone#______________________
Person Responsible Employed by:__________________________________________Occupation:_________________
Business Address:_______________________________________________Business#___________________________
Insurance Company:_________________________________ Insurance#________________________________
Insurance Address:_________________________________________________________________________
Group#_______________________ Subscriber#_______________________________
ADDITIONAL INSURANCE
Is patient covered by additional insurance? Yes/NO__________
Subscriber Name:_______________________ Subscriber DOB:___________ Subscriber ID#/SS# ____________________
Address If different from Patient:_________________________________________________________Phone#______________________
Person Responsible Employed by:__________________________________________Occupation:_________________
Business Address:_______________________________________________Business#___________________________
Insurance Company:_________________________________ Insurance#________________________________
Insurance Address:______________________________________________________________________
Group#_______________________ Subscriber#_______________________________
DENTAL HISTORY
Reason for Today’s Visit ___________________________________________________________
Date of Last dental visit ________________
Former Dentist_____________________________ Date of last dental
X-rays____________________
Address____________________________________________________________________________
Check if you have had problems with the following:
___ Bad breath
___ Bleeding gum
___ Clicking or popping jaw
___ Food collection between teeth
___ Grinding Teeth
___ Loose teeth or broken fillings
___ Periodontal Treatment
___ Sensitivity to cold
___ Sensitivity to hot
___ Sensitivity to sweets
___ Sensitivity when biting
___ Sores or growths in the mouth
MEDICAL HISTORY
Physician Name:_______________________________ Date of Last Visit:_________________________
Have you had any serious illness or operations? Yes/No If yes, describe? ___________________________________
Have you ever had a blood transfusion? __Y__N If yes, give approximate date_________________________
Have you ever taken any of the group of drugs collectively referred to as “fen-phen”? These include combinations of Lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). __Yes/__No
Are you pregnant? ________________________ Nursing?________________ Taking Birth Control Pill?____________
Check if you have or have had any of the following:
___Anemia
__Arthritis, Rheumatism
___Artificial Heart Valves
___Asthma
___Back Problems
___Blood Diseases
___Cancer
___Chemical Dependency
___Chemotherapy
___Circulatory Problems
___Cortisone Treatments
___Cough, Persistent
___Diabetes
___Epilepsy
___Fainting
___Glaucoma
___Headaches
___Heart Murmur
___Heart Problems
___Hemophilia
___Hepatitis
___High Blood Pressure
___HIV/AIDS
___Jaw Pain
___Kidney Disease
___Liver Disease
___Mitral Valve Prolapse
___Pacemaker
___Radiation Treatment
___Respiratory Disease
___Rheumatic Fever
___Scarlet Fever
___Shortness of Breath
___Skin Rash
___Stroke
___Swelling of Feet or Ankles
___Thyroid Problems
___Tobacco Habit
___Tonsilitis
___Tuberculosis
___Ulcer
___Venereal Disease
AUTHORIZATION
I certify that I, and/or my dependent(s), have insurance coverage with ____________________________(Name of Insurance) and assign directly to Dr. _________________________________ all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Signature of Ptient,Parent,Guardian or Personal Representative:___________________________________________
Print Name:_________________________________________ Date:_________________________
Relationship to Patient: _____________________________
Payment is due in full at the time of treatment unless prior arrangements have been approved.
GENERAL DENTISTRY INFORMED CONSENT
Patient: _________________________________________________________________
Drugs and Medication: I understand that antibiotics and/or other medications prescribed to me may cause allergic reactions causing redness and swelling of tissue, pain, itching, vomiting, and or/ anaphylactic shock. For this reason, I have provided the doctor/ staff with all my medical history to the beast of my knowledge.
Changes in Treatment Plan: I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during the initial examination. For example, Root Canal therapy following routine restorative procedures. I give my permission to my dentist to make any/all changes and additions, as necessary.
I understand that dentistry is not an exact science and that therefore, reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatments which have requested and authorized.
I hereby authorize any of the doctors or dental auxiliaries to proceed with and perform the dental restorations and treatments as explained to me. I understand that this is only an estimate and subject to modification depending on unforeseen or undiagnosable circumstances that may arise during the course of treatment. I understand that regardless of any dental insurance coverage I may have, I am responsible for the payment of dental fees. I agree to pay any attorney fees or court costs, that may be incurred to satisfy the obligation.
Signature of Patient:__________________________________ Date:__________________________
Signature of Doctor:__________________________________ Date:______________________
ACKNOWLEDGMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES
(“Acknowledgment”)
I acknowledge that I have received a copy of this Dental Practice’s HIPAA Notice of Privacy Practices.
Patient Name: _____________________________________________
Patient Signature:__________________________________________ Date:__________________________
OR
Signature of Personal Representative: ____________________________________
Authority of Personal Representative to Sign for Patient (check one)
___ Parent ___ Guardian ___Power of Attorney __Other
Please Note: It is your right to refuse to sign this Acknowledgment.
Dental Office Use Only
I tried to obtain written Acknowledgment by the individual noted above of recipient of our Notice of Privacy Practices, but it could not be obtained because:
____ An emergency prevented us from obtaining acknowledgment.
____ A communication barrier prevented us from obtaining acknowledgment.
____ The individual was unwilling to sign.
____ Other:_____________________________________________________________________________
Staff Member Signature:________________________________________ Date:______________________
