525 Alexandria Pike, Suite 330 Southgate, KY

Transcription

1 525 Alexandria Pike, Suite 330 Southgate, KY Date PATIENT INFORMATION Name Please Circle : Married Single Minor Male Female Address City State Zip Date of Birth Social Security Number Telephone Home Work Cell Important: Please provide us with your cell phone number or the number that is best to reach you in case of an emergency. It will save both you and us valuable tme. Has anyone in your family been seen by our ofcec No Yes Name address Herald Family Dentstry has an system that will help maintain your appointments Employer or school Grade If patent is a minor, please include parentgguardian s name(s INSURANCE INFORMATION Insurance Company Group Number If someone other than yourself carries your insurance please provide us with the following informaton: Insurance Carrier s Informaton: Name Relatonship to Patent Date of Birth Social Security Number Address City State Zip Employer IN CASE OF EMERGENCY PLEASE CONTACT: Name Phone Number Address City State Zip Who may we thank for referring you to our ofcec

2 AGREEMENT Insurance: I understand that the porton of my treatment not covered by insurance is due and payable at each visit. I also understand that my dental insurance is a contract between me and the insurance carrier, and not between my insurance carrier and the dentst, and I am stll responsible for dental fees. If my insurance company has not paid their porton within 30 days of being properly billed, I understand that the balance will become due and payable from me. Service Charge: If I do not pay the entre New Balance (the amount due now on your statement within 30 days of the date of service, a SERVICE CHARGE will be added to my account for the current monthly billing period. The SERVICE CHARGE will be a periodic rate of 2% per month which is an ANNUAL PERCENTAGE RATE of 24%. In the case of default of payment, I promise to pay any legal interest on the balance due, together with any collecton agency costs and reasonable atorney fees incurred to efect collecton on this account. CONSENT The undersigned hereby authorizes Doctor to take Xrays, study models, photographs, or any other diagnostc aids deemed appropriate by Doctor to make a thorough diagnosis of the patent s dental needs. I also authorize Doctor to perform any and all forms of treatment, medicaton and therapy that may be indicated. I also understand the use of anesthetc agents embodies a certain risk. I understand that responsibility for payment of Dental Services provided in this ofce for myself or my dependants is mine. I further understand that a fnance charge will be added to any overdue balance. I also assign all insurance benefts to the Doctor and authorize the release of any informaton to my insurance company for consideraton of claims to be processed. Signature of Responsible Party Date

3 MEDICAL HISTORY * Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entre body. Health problems that you may have, or medicaton that you may be taking, could have an important interrelatonship with the dentstry you will receive. Thank you for answering the following questons. Your Name: Today s Date: Family Physician Name: Date of last Visit: Have you ever been informed that you need pre-medicaton prior to dental treatmentc if yes describe: Have you had any serious illness or operatonsc if yes, describe: Have you ever had a blood transfusionc If yes, give approximate dates: Women: Are you pregnant? Nursing? Birth Control Pills? CHECK NEXT TO ANYTHING THAT APPLIES: Anemia Cortisone Treatments Hepatitis Scarlet Fever Arthritis, Rheumatism Cough, Persistent High Blood Pressure Shortness of Breath Artificial Heart Valves Cough Up Blood HIV/AIDS Skin Rash Artificial Joints Diabetes Jaw Pain Stroke Asthma Epilepsy Kidney Disease Swelling Feet/Ankles Back Problems Fainting Liver Disease Thyroid Problems Blood Disease Glaucoma Mitral Valve Prolapse Tobacco Habit Cancer Headaches Pacemaker Tonsillitis Chemical Dependency Heart Murmur Radiation Treatment Tuberculosis Chemotherapy Heart Problems Respiratory Disease Ulcer Circulatory Problems Hemophilia Rheumatic Fever Venereal Disease Acid Reflux Any other conditions not listed: History of Bisphosphonates? (Osteoporosis drug. Ex: Fosamax) YES / NO If yes, please describe: Allergies: NONE Codeine Penicillin Sulfa Latex Ibuprofen Other: MEDICATIONS. Please list medications you are currently taking To the best of my knowledge, the questons on this form have been accurately answered. I understand that providing incorrect informaton can be dangerous to my (or patent s health. It is my responsibility to inform the dental ofce of any changes in medical status. SIGNATURE OF PATIENT, PARENT, or GUARDIAN Date

4 Dental History Chief dental concern/reason for today s visit Current Tobacco user what kind How muchgday for how long History of Periodontal Diseaseg Scaling and Root Planning. If yes, provide date Previous Tobacco user When did you quit Family History of gum disease (parents lost teeth at early age or gum disease on your side of family Stress (death of spouse, divorcegseparaton, death in family, injurygillness, retrement, loss of job, etc. Bleeding of Gums. Taking Dilantn, Caa Channel Blockers, or Immunosuppressant s for organ transplantaton Gums swollen or tender. Jaw pain or tenderness. Loose teethg Broken Fillings. Grinding teeth. Dry Mouth Orthodontc Treatmentc If yes, provide date How often do you Flossc How often do you Brushc If you could change anything about your smile, what would you change? Explain:

5 PRESCRIPTION/DRUG POLICY Prescriptons will not be flledgreflled after normal business hours, on holidays or weekends when the doctor on call does not have your records. This is for your safety and the safety of others. An early refll on your pain medicine will NOT be granted if you take more than the prescribed amount. In the event of an emergency in which the Dentst cannot be contacted, you are instructed to visit the nearest urgent care facility. Prescriptons will not be flledgreflled if you have cancelled your last appointment, did not show up for your last appointment, if you do not follow through with recommended dental treatment in a tmely manner, you have been discharged from the practce, or if you were to return only as needed. WE DO NOT PRACTICE PAIN MANAGEMENT. Prescriptons that have been lost (or discarded will not be reflled. Prescriptons that have been stolen will not be reflled. During the tme of your care at this ofce, it is your responsibility to inform the Dentst of any and all medicatons you are currently taking as well as any medicatons that you have been recently prescribed. It is our legal duty to report to the authorites the name of a patent whom we believe may be taking, selling, or distributng narcotcs or other medicatons illegally. We reserve the right to terminate the doctor-patent relatonship in the event of any breech in this policy by the patent. I HAVE READ THE ABOVE AND UNDERSTAND THE PRESCRIPTION POLICIES. Patent Signature Date

6 Acknowledgement of Receipt of Notce of Privacy Practces. I, (Print Name, have received a copy of this ofces Notce of Privacy Practces. Please Print Patent Name: Signature: Date: FOR OFFICE USE ONLY We atempted to obtain writen of receipt of our Notce of Privacy Practces, but acknowledgement could not be obtained because: Individual refuse to sign. Communicaton barriers prohibited obtaining the acknowledgment. An emergency situaton prevented us from obtaining acknowledgment. Other. (Please Specify.