Whom do we thank for referring you?

Transcription

1 Patient Information Chart #: FOR OFFICE USE ONLY Patient Name: Date: Last, First MI (Preferred Name) Gender: Family Status: Social Security #: Birth Date: Phone (Home): (Work): (Cell): Street Apartment # Emergency Contact (name,ph#): City State Zip Code Whom do we thank for referring you? Health Information Date of Last Dental Visit: Reason for today s visit: Have you ever had any of the following? Please check those that apply: AIDS or HIV infection Fainting/Seizures Anemia Glaucoma Angina Hay Fever/Allergies Arthritis Heart Attack Artificial Joints date Heart Disease Asthma Heart Murmur Blood Disease Hepatitis/Jaundice Cancer /Leukemia High Blood Pressure Chest Pain Kidney Disease Diabetes Liver Disease Dizziness Mental Disorders Emphysema Mitral Valve Prolapse Epilepsy Nervous Disorders Excessive Bleeding Pacemaker Radiation Treatment Recent Weight Loss Respiratory Problems Rheumatic Fever Rheumatism Sinus Problems Snoring or sleep apnea Stomach Problems/Ulcers Stroke Thyroid Problems Tuberculosis Tumors Winded Easily Venereal Disease Drug Allergies: Codeine Allergy Penicillin Allergy Local Anesthetics Sulfa drugs Sedatives Aspirin Any Metals (e.g. nickel) Latex Rubber Other Do you need an antibiotic pre-medication for your dental appointments? Y N Have you ever been treated by a periodontist (gum specialist)? Yes No If you could change your smile, what would you do? Do your gums bleed while brushing or flossing? Yes No Have you ever had any prolonged bleeding? Yes No Does the dental office make you anxious or nervous? Yes No Do you feel tooth sensitivity or pain? Yes No Would you like to sleep (be sedated) during your dental Circle those that apply to you: hot/cold sweet biting constant treatment for any of the reasons listed below? Yes No Do you have any sores or lumps in or near your mouth? Yes No (Please circle any that apply): gag reflex dental phobic Have you had any head, neck or jaw injuries? Yes No needle phobic noise phobic odor phobic difficulty Do you experience jaw problems? Yes No Getting numb would like everything done in one visit Circle those that apply Clicking pain (joint, ear, side of face) Difficulty opening or closing Yes No Would you like to hear about different options on replacing missing teeth? If yes, circle the things you d Do you clench or grind your teeth? Yes No like to know more about. dentures partials bridges implant Have you ever had difficult extractions in the past? Yes No Have you been hospitalized within the last five years? Yes No Do you like your smile? Yes No If yes, please explain Have you had any orthodontic treatment? Yes No Please list any medication(s), dose and reason for taking Do you wear dentures or partials? (Date of placement Yes No them Are you happy with them? Yes No Do you use smoke or vape? Pack per day? Years? Yes No Do You chew tobacco? Years? Yes No Are you wearing contact lenses? Yes No Do you have frequent headaches? When? Am. Pm, other Yes No Have you ever had oral hygiene instructions? Yes No Have you ever taken Phen-Fen/Redux? Yes No Yes No

2 Do you use controlled substances? Yes No If I ever have any change in my health, I will inform the doctors at the next appointment without fail. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information to third party payers and /or health practitioners. Date: Signature of patient, parent or guardian

3 Spouse or Responsible Party Information The following is for: the patient's spouse the person responsible for payment Name: Male Female Married Single Child Other Social Security #: Birth Date: Phone (Home): (Work): (Cell): Street Apartment # City State Zip Code Employment Information The following is for: the patient the person responsible for payment Employer Name: Occupation: Street City, State Zip Code Phon Insurance Information Primary Name of Insured: Is insured a patient? Yes No Last First MI Insured's Birth Date: ID #: Group #: Insured's Insured's Employer Name: Patient's relationship to insured: Self Spouse Child Other Insurance Plan Name and Secondary Name of Insured: Is insured a patient? Yes No Last First MI Insured's Birth Date: ID #: Group #: Insured's Insured's Employer Name: Patient's relationship to insured: Self Spouse Child Other Insurance Plan Name and «SInsName»

4 STANDARD CONSENT FOR DENTAL PROCEDURES PLEASE READ THIS FORM CAREFULLY I, hereby authorize Dr. Hathaway, and whomever he may designate as his assistants, to perform upon me the surgery/procedure(s) that have been explained to me. I have requested and I now authorize Dr. Hathaway to do whatever he deems advisable if any unforeseen condition arises in the course of this designated surgery/procedure(s) after having been advised of the risks, advantages and disadvantages, and the consequences of non-treatment. I consent to the surgery/procedure(s) after having been advised of any alternate plans of treatment available, known material risks, and the advantages and/or disadvantages of any alternative treatment. I further consent to the administration of local anesthesia, antibiotics or any other drug that may be deemed necessary for dental treatment, and I understand that there is an element of risk inherent in the administration of any drug or anesthesia. This risk includes adverse drug response (e.g., allergic reactions), cardiac arrest, and aspiration, pain, discoloration and injury to blood vessels and nerves which may be caused by injections of any medications or drugs. I have been informed, and I fully understand, that inherent in any type of surgery/procedure(s) there are certain unavoidable complications. The most common of these complications include post-operative bleeding, swelling or bruising, discomfort, stiff jaws, loss or loosening of other dental restorations. Less common complications can include infection, continued numbness in mouth and lip tissues, jaw fractures, sinus exposure and bone fragments remaining in the jaw which might require extensive surgery for removal. I realize that in spite of the possible complication and risks, my contemplated surgery/procedure(s) in necessary and desired by me. I am aware that the practice of dentistry in not an exact science and that unknown conditions found may change the treatment recommendations and the fee that has been discussed and agreed by me. I understand that I will be informed of any changes to my surgery/procedure(s) at the realized convenience; however, I consent to the necessary condition found. I acknowledge that no guarantees have been made to me concerning the results of the surgery/procedure(s) being performed. I also consent to photographs being taken. I understand they will be used for illustration and for documentation of my treatment. I have provided an accurate and complete medical and personal history as possible, including those antibiotics, drugs and foods to which I am allergic. I will follow any/all instructions during, and after my surgery/procedure(s) as it is explained to me and I agree to report any unanticipated reactions to Dr. Hathaway as soon as possible. I have had the opportunity to ask questions about my surgery/procedure(s) and responsive explanations have been given to me. I understand that additional appointments may be required and I agree to the terms of the cancellation policy. I understand that I may be charged a fee if I fail to inform the office at least 48 hours in advance of any reserved appointment that I may cancel. Your insurance policy is a contract between you and your insurer. Benefits are determined by your employer and not your dentist. I understand that Evan Hathaway D.D.S., PA will file my claims as a courtesy for me and I agree to pay any balance or co-pay at time of service. If my insurance company sends payment to me directly I understand that I may be asked to pay my balance in full. I understand that financial arrangements must by made prior to scheduling an appointment for treatment, and a deposit of up to 50% of the treatment fee is required. I am knowledgeable, and I agree, to the fees associated with the treatment recommendations and I agree to be responsible for the full payments of the surgery/procedure(s) rendered. I understand that a 21% finance charge per month will be added to my account for any balance over 30 days, regardless of any pending insurance claims and possibly sent to a third party collector. I understand that I am responsible for any fees/costs that may be incurred for the collections of my account (e.g. collections agency fees, courts, and attorney fees). Patient Signature Date If minor, signature of parent or guardian Date

5 Our new cancellation office policy is as follows for all future appointments: If you have an appointment and do not show, cancel or reschedule with short (less than 24 hours) or no notice there will be a 25% deposit of the appointment value required to reschedule the missed appointment. This deposit will be refunded to you after you maintain your scheduled appointment and your insurance has paid. If you NO SHOW again, it will not be refunded to you. This policy applies to Hygiene / Dental cleanings and treatment appointments. We understand that things come up, but repeated occurrences are difficult to manage. We exclusively reserve time just for you on our schedule. We make specific preparations and instrument set ups in treatment rooms for individualized treatment. This all needs to be disassembled and restocked when we miss you. Thank you for your understanding and consideration as we manage this problematic situation we have been facing. Signature NOTICE OF PRIVACY PRACTICES-ACKNOWLEDGEMENT We keep a record of the health care services we provide you. You may ask to see and copy that record. You may also ask to correct that record. We will not disclose your record to others unless you direct us to do so or unless the law authorizes or compels us to do so. Our Notice of Privacy Practices describes in more detail how your health information may be used and disclosed and how you can access your information. Patient or legally authorized individual signature Date Time