Insurance Company: Group No.: Insurance address: City:

Transcription

1 Patient Information First Name: Last Name: Middle Initial: Preferred Name: Birth Date: / / Age: Sex: Male Female Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Preferred Phone# for us to communicate with you: Receive Text Message Reminders? Y/N Can we leave a message? Yes No Social Security Number: - - Drivers License Number: State: Marital Status: Single Married Divorced Separated Widowed I would like to receive correspondence and appointment info. Via Employment Status: Full Time Part Time N/A If Employed, Employer Name: Student Status: Full Time Part Time N/A If Student, Name of School/College: Whom may we thank for referring you? Responsible Party (If someone other then patient) Person Responsible for this Account: Relationship to Patient: Address: City: State: Zip Code: Home Phone: Work Phone: Cell Phone: Social Security Number: - - Birth Date: / / Drivers License #: ST: Is this person currently a patient in our office? Yes No Dental Insurance Insurance Company: Group No.: Insurance address: City: State: Zip Code: Insurance Phone Number: Name of Insured: Relationship to Patient: Insured s Social Security Number: - - Insured s Birth Date: / / Insured s Employer Name: Insured s ID no.: Patient Signature: Date: / / (or Parent/Guardian if patient is under 18 years of age)

2 DENTAL HISTORY Patient Name: Birth Date: / / Date of your last cleaning / / What is the most important thing to you about your dental visit today? What was done at your last dental visit? Name of previous dentist/city/state How often do you have dental exams? How often do you brush your teeth/floss? What dental aids do you use? DO YOU TAKE ANTIBIOTICS BEFORE DENTAL APPOINTMENTS? yes no On a scale of 1-10, with 10 being the highest rating: How important is your dental health to you? Where would you rate your current dental health? Where do you want your dental health to be? What is the most important thing to you about your future smile and dental health? Are your teeth sensitive to: Have you ever had? Hot or cold? yes no Orthodontic treatment? yes no Sweets? yes no Oral surgery? yes no Biting or Chewing? yes no Periodontal treatment? yes no Have you noticed any mouth odors/ bad tastes? yes no Had your teeth ground or the bite adjusted? yes no Do you frequently get cold sores, blisters, or any other oral lesions? yes no Do your gums bleed or hurt? yes no Have your parents experienced gum disease or teeth loss? yes no Have you noticed any loose teeth or change in bite? yes no Does food tend to become caught in between your teeth? yes no if yes, where Do you clench or grind your teeth while awake or asleep? yes no Do you bite your lips or cheeks regularly? yes no Do you hold foreign objects with your teeth? yes no (pencil, pipe, pins, nails) Do you mouth breathe while awake or asleep? yes no Do you have tired jaws, especially in the morning? yes no Do you snore or have any other sleeping disorders? yes no Do you use tobacco products? yes no Have you experienced? Clicking or popping of the jaw? yes no Pain (joint, ear, or side of face)? yes no Difficulty in chewing on either side of your mouth? yes no Difficulty with opening or closing your mouth? yes no Headaches, neck aches or shoulder aches? yes no describe Had a serious injury to the mouth or head yes no if yes, please Would you like to keep all of your teeth for life? yes no Are you satisfied with your teeth s appearance? yes no Do you feel nervous about having dental treatment? yes no If yes, what is your biggest concern? Have you ever had an upsetting dental experience? yes no Please describe Patient Signature date (Guardian if patient is under 18)

3 Medical History Patient Name Birth date / / Physician: Office number Are you under a physician s care now? Yes/No If yes, please explain why: Have you ever been hospitaized or had a major operation? Yes /No If yes, please explain Have you ever had a serious head /neck injury? Yes/No If yes,please explain Are you taking any medication(s) including non-prescription medicine? Yes No If yes, please list all: Do you take or have you taken, Phen-Fen or Redux? Yes No Are you on a special diet? Yes No Do you use tobacco? Yes No Do you use controlled substances? Yes No Are you wearing contact lenses? Yes No WOMEN ONLY: Are you pregnant/think you may be pregnant? Yes/No Are you nursing? Yes /No Are you taking oral contraceptives? Yes/No ARE YOU ALLERGIC TO ANY OF THE FOLLOWING? Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Sulfa Other DO YOU REQUIRE ANTIBIOTICS BEFORE DENTAL APPOINTMENTS? Yes No HAVE YOU HAD ANY OF THE FOLLOWING? AIDS/HIV Positive Chest Pains Genital Herpes Kidney Problems Sickle Cell Dis. Alzheimer s Disease Cold Sores/Fever Blisters Glaucoma Leukemia Sinus Trouble Anaphylaxis Congenital Heart Disorder Hay Fever Liver Disease Spina Bifida Anemia Convulsions Heart Attack/Failure Low Blood Pressure Stomach/Intstnl Angina Cortisone Medicine Heart Murmur Lung Disease Stroke Arthritis/Gout Diabetes Heart Pace Maker Mital Valve Prolapse Swelling of Limbs Artificial Heart Valve Drug Addiction/Alcoholism Heart Trouble/Disease Pain in Jaw Joints Thyroid Disease Artificial Joint Erectile Dysfunction Hemophilia Parathyroid Disease Tonsillitis Asthma Emphysema Hepatitis A Psychiatric Care Tuberculosis Blood Disease Epilepsy or Seizures Hepatitis B/C Radiation Treatments Tumors/Growths Blood Transfusions Excessive Bleeding Herpes Recent Weight Loss Ulcers Breathing Problems Excessive Thirst High Blood Pressure Renal Dialysis Bruise Easily Fainting Spells/Dizziness High Cholesterol Rheumatic Fever Cancer Frequent Cough Hives or rash Rheumatism Type of Cancer Frequent Diarrhea Hypoglycemia Scarlet Fever Chemotherapy Frequent Headaches Irregular Heart Beat Shingles Have you ever had any serious illness not listed above? Yes No Please explain To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform of any changes in my medical history. Patient Signature Date / / (Guardian if patient is under 18 years of age)

4 Authorization For Release of Information Patient Name Date of Birth Address City State Zip Code Office to Release Information: Name Phone Fax Address City State Zip Code Office to Receive Information: Name Phone Fax Address: N. Hwy 16 City Denver State NC Zip Code Description of information to be released: X-Rays Rights to patient: I understand that I have the right to revoke this authorization at any time by sending a written notification. I understand revocation is not effective in cases where the information has already been used or disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by Federal or State Law. I understand I have the right to inspect or copy the protected health information to be used or disclosed as described in this document by written notification. Patients Name Signature Date

5 AUTHORIZATION TO RELEASE INFORMATION Name of Patient Date of Birth WEST LAKE DENTISTRY is authorized to release protected health information about the above named patient to the entities named below. The purpose is to inform the patient or others in keeping with the patient s instructions. ENTITY TO RECEIVE INFORMATION: Check each person/entity that you approve to receive information: Voic Check each that can be given to person/entity on left Results of lab tests/x-rays Only as follows: Spouse (provide name & phone #) Only as follows: Parent (provide name & phone #) Only as follows: Other (Provide name & phone # ) Only as follows: Patient Information I understand that I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclosed as described in this document. I understand that a revocation is not effective in cases where the information has already been disclosed but will be effective going forward. I understand that information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no longer be protected by federal or state law. I understand that I have the right to refuse to sign this authorization and that my treatment will not be conditioned on signing. This authorization shall be in effect until revoked by the patient. date Signature of patient OR Personal Representative (description of Personal Representative s Authority (attach necessary documentation)

6 Acknowledgement of Receipt of Notice of Privacy Practices Patient Name Address: I have received a copy of the Notice of Privacy Practices for the above name practice. Signature Date For office use only We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because: An emergency existed & a signature was not possible at the time. The individual refused to sign. A copy was mailed with a request for a signature by return mail. Unable to communicate with the patient for the following reason: Other Prepared by : Signature: Date

7 Financial/Payment Policy The following information is to inform you of s financial policy. We appreciate the trust you have placed in us. If at any time you have questions regarding this policy, please do not hesitate to ask our Financial Coordinator. is committed to providing you with the best possible dental care. Our fees reflect the exceptional level of care, predictability and long-term satisfaction that our clients receive. We will communicate clearly all recommended treatment and fees involved prior to beginning treatment. Patients estimated portion is due at the time of service. If your insurance company does not cover the estimated insurance portion of your treatment, the fee becomes your responsibility and will be paid within the above parameters. If we later receive payment from your insurance company, we will gladly reimburse you the covered amount. Please understand that professional services are rendered and charged to you, not the insurance company. It is the patient s ultimate responsibility to know and understand his or her insurance company. Additional office fees include: $40 processing fee for checks with insufficient funds or if a stop payment is placed on an issued check. We accept cash, check, Master Card, Visa, Discover, American Express, Care Credit and Wells Fargo Health Advantage. Please consider and schedule appointments carefully. We require 24 hours notice to cancel an appointment. If we do not receive at least a 24 hour notice we will charge a broken appointment fee of $56 for hygiene appointments. treatment appointments we would like a 48 hours notice, however less than 24 hours notice will result in a fee of 20% of your scheduled appointment. This cannot be charged to your insurance company. Our goal is to fill all appointment times for the benefit of our patients and having this policy allows us to meet this goal. Our goal at is to offer comfortable payment options that allow our clients to have the benefit of lasting health, an attractive smile and the high quality of care that Dr. Naylor provides. Client/Patient Name (Please Print): Client/Patient Signature: Date: / /