Today s Date: Name: Birthdate: / / SS#: Home #: Work #: Cell #: Best Time to Contact You:

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1 Today s : Name: Nickname: Male Female Birthdate: / / SS#: Home #: Work #: Cell #: Best Time to Contact You: Preferred Method of Contact: Please choose all that apply. Home Work Cell Text Address: Apt. #/Floor City: State: Zip: Marital Status: Single Married Divorced Widowed Whom may we Thank for referring you? Previous Dentist: Last Visit : EMPLOYER INFORMATION Employer: Occupation: How long have you been employed there? Employer s Address: PRIMARY DENTAL INSURANCE Insurance Company Name: Insurance Co. Address: Insurance Co. Phone #: Group #: Insured s Name: Insured s Birthdate: / / ID #: Insured s Employer: SECONDARY DENTAL INSURANCE Insurance Company Name: Insurance Co. Address: Insurance Co. Phone #: Group #: Insured s Name: Insured s Birthdate: / / ID #: Insured s Employer: PHYSICIAN S INFORMATION Primary Physician s Name: Phone #: Are you currently under the care of a physician? Yes No City: State: Zip: In the event of an emergency, whom should we contact? Please explain: Name: Relationship: Home #: Cell #:

2 Your current physical health is: Good Fair Poor Are you taking any prescription / over-the-counter or supplemental drugs? Y N Please list each one: Do you smoke or use tobacco in any other form? Y N Have you ever taken Fosamax, or any other bisphosphonate? Y N Have you been told that you snore or hold your breath while sleeping or wake up gasping for breath? Y N FOR WOMEN: Are you using a prescribed method of birth control? Y N Are you pregnant? Y N Week #: Are you nursing? Y N Please list any serious medical condition(s) that you have ever had: MEDICAL HISTORY Are you allergic to any of the following? Y N Aspirin Y N Erythromycin Y N Penicillin Y N Codeine Y N Jewelry / Metals Y N Tetracycline Y N Dental Anesthetics Y N Latex Y N Other Please list any other drugs / materials that you are allergic to: DENTAL HISTORY Why have you come to the dentist today? Do you require antibiotics before dental treatment? Y N Are you currently in pain? Y N Have you ever had a serious/difficult problem associated with any previous dental work? Y N Do you now or have you ever experienced pain/discomfort in your jaw joint (TMJ/TMD)? Y N Do you like your smile? Y N Do your gums ever bleed? Y N Have you ever had periodontal disease? Y N Have you ever had any of the following disease or medical problems? (Please circle the option that applies.) Y N Anemia/Radiation Treatment Y N Artificial Bones / Joints / Valves Y N Arthritis Y N Asthma Y N Blood Transfusion Y N Cancer / Chemotherapy Y N Congenital Heart Defect Y N Diabetes Y N Difficulty Breathing Y N Drug / Alcohol Abuse Y N Emphysema / Glaucoma Y N Epilepsy / Seizures / Fainting Spells Y N Fever Blisters / Herpes Y N Heart Attack / Stroke Y N Heart Murmur Y N Heart Surgery / Pacemaker Y N Hemophilia / Abnormal Bleeding Y N Hepatitis Y N High Blood Pressure Y N Low Blood Pressure Y N HIV+ / AIDS Y N Hospitalized for Any Reason Y N Kidney Problems Y N Mitral Valve Prolapse Y N Psychiatric Treatment Y N Rheumatic / Scarlet Fever Y N Severe / Frequent Headaches Y N Shingles Y N Sickle Cell Disease / Traits Y N Sinus Problems Y N Tuberculosis (TB) Y N Ulcers / Colitis Y N Veneral Disease Y N Other PHOTOGRAPHY CONSENT/RELEASE I,, hereby grant permission to Totowa Dental Center to take and use photographs and/or digital images and/or videos of me for use in educational and marketing materials. I authorize the use of these images and/or videos without compensation to me. Signature I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. Signature

3 PATIENT HIPAA CONSENT FORM I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as: a basis for planning my care and treatment a means of communication among the many health professionals who contribute to my care a source of information for applying my diagnosis and surgical information to my bill a means by which a third-party payer can verify that services billed were actually provided a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I ve provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon. Patient/Parent/Guardian Signature

4 Changed Your Mind? OUR CANCELLATION POLICY KINDLY GIVE 24 HOURS NOTICE FOR CANCELLATION OF APPOINTMENTS. NON-APPEARANCES FOR SCHEDULED APPOINTMENTS WILL BE SUBJECTED TO A BROKEN APPOINTMENT FEE OF $ THIS POLICY IS TO INSURE THAT OTHERS ARE GIVEN THE OPPORTUNITY OF BEING SEEN AND TREATED IN A TIMELY MANNER. THANK YOU FOR YOUR COOPERATION. PATIENT SIGNATURE: DATE:

5 Totowa Dental Center Office Policies 360 US-46, Totowa NJ Phone: (973) Cancellation Policy: Kindly give 24 hours notice for cancellation of appointments. Non-appearances for scheduled appointments will be subjected to a broke appointment fee of $ This policy is to insure that others are given the opportunity of being seen and treated in a timely manner. Thank you for your cooperation. Insurance Policy: Upon receipt of our patient s insurance information, Totowa Dental Center will call for a detailed breakdown on the patient s behalf. All information attained therein will be used to help both the patient and the office staff understand the patient s financial responsibility. Despite the fact that we receive this information, we would like to make all patients aware that the breakdown is not a guarantee of coverage until the procedure is completed and submitted to the insurance. Therefore, any procedure not covered by the insurance will become the patient s responsibility. Patient Signature