David P. Price, DDS, PA Family Dentistry
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- Robert Marcus Cameron
- 6 years ago
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1 PATIENT NAME David P. Price, DDS, PA Family Dentistry Welcome to our Practice! We are glad you are here! Please complete the following forms. PATIENT INFORMATION PATIENT'S SOCIAL SECURITY NUMBER_ OCCUPATION DATE OF BIRTH SEX M MARITAL STATUS S D M PHONE NUMBER (INCLUDING THE AREA CODE) HOME WORK CELL WHOM MAY WE THANK FOR REFERRING YOU TO OUR OFFICE? GUARANTOR INFORMATION PERSON RESPONSIBLE FOR PAYMENT _ PHONE NUMBER (INCLUDING THE AREA CODE) HOME WORK CELL DATE OF BIRTH Dental fees are ALWAYS due at the time services are rendered. Please indicate how you will be paying for today's dental procedures. Dental Insurance Check Cash MasterCard Care Credit Discover Visa
2 DENTAL INSURANCE PRIMARY DENTAL INSURANCE NAME OF EMPLOYEE EMPLOYEE DATE OF BIRTH, SOCIAL SECURITY NUMBER OF EMPLOYEE, NAME OF EMPLOYER NAME OF INSURANCE COMPANY, GROUP NUMBER SECONDARY DENTAL INSURANCE NAME OF EMPLOYEE EMPLOYEE DATE OF BIRTH SOCIAL SECURITY NUMBER OF EMPLOYEE^ NAME OF EMPLOYER NAME OF INSURANCE COMPANY_ GROUP NUMBER I understand that I am financially obligated to pay the estimated portion of the fee for dental services at the time services are rendered. If there is a difference between the estimated amount and the total amount paid by the insurance company my credit card on file will be charged. COMPLETE PREAUTHORIZATION PAGE. Patient signature
3 TIME David P Price, DOS DATE MEDICAL HISTORY PATIENT NAME Birth 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. Thank you for answering the following questions. Are you under a physician's care now? Have you ever been hospitalized or had a major operation? Q Yes O No If yes, please explain: _ If yes, please explain: Have you ever had a serious head or neck injury? Are you taking any medications, pills, or drugs? If yes, please explain: If yes, please explain: Do you take, or have you taken, Phen-Fen or Redux? Have you ever taken Fosamax, Boniva, Actonel or any ^ ^ other medications containing bisphosphonates?^ s ^ " Are you on a special diet? Do you use tobacco? Do you use controlled substances?.women: Are you I Pregnant/Trying to get pregnant? O YesQ No Taking oral contraceptives? Q YesQ Nursing? Q YesQ No Are you allergic to any of the following?- - I Aspirin j Penicillin Codeine Local Anesthetics Acrylic Metal Latex Sulfa drugs Q Other If yes, please explain: _ Do you have, or have you had, any of the following? AIDS/HIV Positive Alzheimer's Disease Anaphylaxis O Yes Q No Anemia O Yes Q N Angina Arthritis/Gout O Yes Q No Artificial Heart Valve Artificial Joint Q Yes Q No Asthma Blood Disease Q Yes Q No Blood Transfusion Breathing Problem Bruise Easily O Yes Q NO Cancer O Yes O N Chemotherapy O Yes Q No Chest Pains O Yes Q N Cold Sores/Fever Blisters Congenital Heart DisorderQ Yes O No Convulsions Cortisone Medicine Diabetes O Yes Q No Drug Addiction O Yes Q No Easily Winded O Yes Q No Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes O Yes Q N Glaucoma Hay Fever Q Yes O No Heart Attack/Failure O Yes O N Heart Murmur Q Yes O N Heart Pacemaker Heart Trouble/Disease Have you ever had any serious illness not listed above? Comments: Hemophilia Hepatitis A O Yes Q No Hepatitis B or C Q Yes O No Herpes High Blood Pressure Q Yes O No High Cholesterol Q Yes O No Hives or Rash Hypoglycemia Irregular Heartbeat Q Yes O No Kidney Problems Q Yes Q No Leukemia Liver Disease O Yes Q No Low Blood Pressure Q Yes O No Lung Disease Mitral Valve Prolapse Osteoporosis O Yes O N Pain in Jaw Joints Parathyroid Disease Q Yes Q No Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice 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 (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. SIGNATURE OF PATIENT, PARENT, or GUARDIAN DATE
4 AUTHORIZATION TO RELEASE HEALTH INFORMATION Expires upon one time release Patient Information: Name of Patient of Birth _ Address City, I authorize the practice below to release my health information: Please forward/release my health information to: David P. Price, D.D.S., P.A. Phone: Family Dentistry Fax: P. O. Box 865 Lillington, North Carolina The information below is provided at the request of the patient. This authorization shall be in effect until the information has been forwarded as requested. Patient Information I understand that my treatment will not be conditioned on signing this authorization and that I have the right to refuse to sign this authorization. I understand that information disclosed as a result of this authorization may be subject to redisclosure by the recipient and may no linger be protected by federal or state law. I understand that I have the right to revoke this authorization by sending a written notification to the address below and that a revocation is not effective if the information has already been disclosed but will be effective going forward. I understand that I have the right to inspect or copy the protected health information as described in this document. I can do this by written notification to Dr. David P. Price, P. O. Box 865, Lillington, NortfiCarolina Signature of Patient or Personal Representative Description of Personal Representative's Authority (attach necessary documentation)
5 David P. Price, DDS, PA PRE-AUTHORIZED HEALTH CARE PAYMENT INSURANCE PATIENTS ONLY Once insurance payment is received, you will be mailed an BOB from your insurance company. If there is an overpayment, a refund check will be issued by our office to the guarantor of the account. If your insurance company does not pay the amount "estimated" by our computer, then a charge will be made to the credit card listed on the form below. If you would like for our office to file your insurance claim - please complete the following information: I authorize the office of David P. Price, DDS, PA to keep my signature on file and to charge my credit card for any balance not paid by dental insurance. I understand that this form is valid for one year unless I cancel the authorization through written notice to the office of David P. Price, DDS, PA. I imderstand that no charge will be placed on my credit card until an BOB is received from the insurance company on file. If my insurance information changes, I agree to provide the updated information to the office of David P. Price, DDS, PA. Patient/guardian signature D Visa D MasterCard D Other PATIENT NAME " CARD HOLDER NAME CITY STATE ZIP CREDIT CARD ACCOUNT NUMBER (Please indicate card name above) EXP. DATE/3 DIGIT CODE CARD HOLDER SIGNATURE DATE Other persons for whom this card may be used
6 David P. Price, DDS, PA Patient Name & Address: Acknowledgement of Receipt Of Notice of Privacy Practices I have received a copy of the Notice of Privacy Practices for the above named practice. Before signing please read "Notice of Privacy Practices" Signature For Office Use Only We were unable to obtain a written acknowledgement of receipt of the Notice of Privacy Practices because: D D IH D 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
7 Authorization for Release of Information Name of Patient of Birth David P. Price, D.D.S., P.A. 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. D Voice Mail Description of information to be released. Check each that can be given to the person/entity on the left in the same section. n Results of Lab Tests/X-Rays n Appointment Confirmation Calls n Spouse n Financial n Medical as follows: n Parent (provide name)_ n Financial a Medical as follows: n Other (provide name)_ n Financial D Medical as follows: Patient Information 1 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. 1 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. Signature of Patient or Personal Representative Description of Personal Representative's Authority (attach necessary documentation)
PATIENT REGISTRATION
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Patient Information Patient Name Mailing Address City State Zip: Home Phone: Cell Phone: Work Phone: Email: Birth Date: / / Age: Sex: Male Female Social Security: Drivers License: Emergency Contact: Phone
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