GRAND STRAND DENTISTRY B Hwy 544. Conway, SC 29526

Transcription

1 GRAND STRAND DENTISTRY 1867 B Hwy 544 Conway, SC I,, hereby authorize Grand Strand Dentistry to give the following people information concerning my health, treatment, billing and/or insurance information: Spouse Name: _ Significant Other Name: _ Any Specified Person Name: _ The following information may be given to the above individual (s) : Appointment Time Pre and Post Op Instructions Any information regarding my dental treatment ************************************************************************ Messages may be left on my answering machine(s) regarding the above: Yes _ NO ************************************************************************ I understand I may terminate this consent anytime by giving written notice to Dr. Brian K. Armstrong. Any changes to this form will require a new consent form to be completed, signed, and dated. Signed: Date: _ Witness: Date: _

2 NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT GRAND STRAND DENTISTRY* 1867 B Hwy 544* Conway, SC I understand that under the Health Insurance Portability and Accountability Act of 1996 ("HIPPA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to contain a current copy of the Notice of Private Practices. I understand that I may request in writing that yo restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations. I also understand you are not required to agree to my restrictions, but if you do agree then you are bound to abide by such restrictions. PATIENT NAME: _ RELATIONSHIP TO PATIENT: _ SIGNATURE DATE: ****************************************************************************** FOR OFFICE USE ONLY I attempted to obtain the patient's signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below: Date: Initials: Reason:

3 GRAND STRAND DENTISTRY Brian K. Armstrong, DMD We are delighted to have you as a dental patient. Our mission is to provide the highest quality dental treatment to our patients. Please read and sign the financial policy below. Please do not hesitate to ask the office manager if any questions or concerns arise regarding the financial policy. Thank you! FINANCIAL POLICY PAYMENT IS DUE AT THE TIME SERVICES ARE RENDERED. ** PAYMENT FOR MAJOR SERVICES IS DUE PRIOR TO PROCEDURE ON PREPARATION DATE. MAJOR SERVICES INCLUDE: ROOT CANALS, CROWNS, BRIDGES, DENTURES, PARITALS AND IMPLANTS.** Our office accepts cash, check, Visa, Master Card, Discover, and American Express. There will be a $30.00 fee for returned checks. We also offer Care Credit for Major services only. As a courtesy, we will file each patient's insurance, but reserve the right to discontinue this service if any problems arise. INSURANCE: We will file insurance for each patient. You are responsible for the deductible and a percentage of the fee that your insurance company considers to be your co-pay. Please be prepared to pay for your deductible and co-payment at each visit. Please understand that although some services provided may not be covered by your insurance company, they are still your responsibility to pay. You will be billed for balances not paid by your insurance company. Minor Patients: The adult accompanying the minor patient is responsible for payment of the services. Missed Appointments/BROKEN APPOINTMENTS: PLEASE HELP US TO SERVE YOU BETTER BY CONTACTING OUR OFFICE AT LEAST 24 HOURS IN ADVANCE, IF YOU ARE NOT ABLE TO KEEP YOUR APPOINTMENT. IT IS OUR POLICY TO CHARGE FOR MISSED APPOINTMENT AT THE RATE OF OUR NORMAL OFFICE VISIT. IF YOU BREAK THREE (3) APPOINTMENTS IN A ROW, YOU WILL NOT BE RESCHEDULED AND DISMISSED FROM OUR PRACTICE. THERE WILL BE A CHARGE OF $15.00 FOR PRESCRIPTIONS CALLED IN AFTER HOURS. I have read and understand the financial policy for Grand Strand Dentistry. Signature of patient/guardian Date

4 Patient s First Name: _ Middle Initial: Last Name: _ Preferred Name: _ Marital Status: _ Date of Birth: Address: City: St: _ Zip: SS#: Home # Cell # _ Address: Who referred you to our office? Employer: Business Phone: Ext: Spouse s Name Employer: _ Business Phone: MINOR PATIENTS: Parent/Guardian Name: _ SS# _ Parent/Guardian Employer: _ Business Phone: In case of an Emergency: Contact Name: Home # _ Physician s Name: Phone # Pharmacy: Phone# _ DENTAL INSURANCE INFORMATION Insurance Name: _ Insured s Name: Insured DOB: ID/SS# of Insured: _Group # Phone # _

5 Patient s Name: HEALTH/DENTAL HISTORY Chief Dental Complaint: Date of last dental visit? Please indicate Yes or No for the following: Bad Breath: Yes No How often do you floss? Bleeding Gums or Mouth Yes No How often do you brush? _ Burning sensations on tongue Yes No Chew on one side of mouth Yes No Are you pregnant? Which Month? Cigarette, Pipe, or Cigar Smoking Yes No Clicking or popping in jaw Yes No Are you allergic to/ Dental Anesthetics? Dry Mouth Yes No or have had Penicillin/Antibiotics? _ Fingernail Biting Yes No a reaction to: Latex? Grinding Teeth Yes No Nickel? _ Loose or broken fillings Yes No Aspirin? Mouth Breathing Yes No Other Drugs? Mouth pain when brushing Yes No Orthodontic Treatment Yes No Have you ever had any difficulties associated with dental Pain around ear Yes No treatment? Periodontal Treatment Yes No Sensitive Hot/Cold/Sweets Yes No Has there been any changes in your general health in the Growths in Mouth Yes No past 5 years? _ Please circle Y or N to the following questions regarding your medical conditions you have or have had: Rheumatic Fever Y or N Heart Problems Y or N Hepatitis Y or N Gland Problems Y or N Heart Disease Y or N Abnormal Bleeding Y or N Aids/HIV Pos Y or N Prosthetic Joints Y or N Blood Disorders Y or N Seizures Y or N Heart Murmur Y or N Stroke/Circulation Y or N Allergies Y or N Glaucoma Y or N Angina Y or N Heart Valve Problems Y or N Tuberculosis Y or N Diabetes Y or N Jaw Pain Y or N Mitral Valve Prolapse Y or N Epilepsy Y or N High Blood Pressure Y or N Stomach Ulcer Y or N Joint Replacement Y or N Kidney Problems Y or N Blood Transfusion Y or N Cancer/Tumor Y or N Thyroid Problems Y or N Acid Reflux Y or N Respiratory Disease Y or N Radiation Tx Y or N Venereal Disease Y or N Sex Trans Disease Y or N PREMED NEEDED? Y or N (ex: For Hip/Knee Replacements or Heart Issues) Please list all medications: To the best of my knowledge, the provided medical/dental/history is correct. I consent to such examinations, x- rays, and diagnostic procedures and test that may be prescribed. I consent to the performing of dental and oral surgery procedures agreed to be necessary or advisable, including the use of general or local anesthetic and indicated photos, and releasing of information to my insurance company. I will assume responsibility for fees associated with any of the above. Patient s (Parent/Guardian) Signature: Date: