Patient Information. Health Information

Transcription

1 PLEASE COMPLETE PRIOR TO YOUR APPOINTMENT. Return Via: Fax: OR Bring to your appointment Patient Information Patient Name: Date: Last First MI Preferred Name Gender: Male OR Female Social Security #: Birth Date: Phone: Home Work Ext: Mobile: Address: Address: Street Apartment # City State Zip Code Health Information 1 Has your Physician ever instructed you to take antibiotics prior to a dental appointment? (If No advance to question #4) YES OR NO 2 If #1 Answer is YES please state reason for premed: 3 Did you premed today? YES OR NO 4 Physician Information: Name and phone number: 5 - Have you ever had any of the following? Please check those that apply: Arthritis Artificial Joints AIDS HIV positive Blood Diseases Anemia Excessive Bleeding Hemophilia Cancer Radiation Treatment Chemotherapy Drug Allergies Latex Allergies Diabetes Dizziness Epilepsy Fainting Glaucoma Hay Fever Head Injuries Heart Disease Angina Artificial Heart Valves Pacemaker Heart Murmur Mitral Valve Prolapse High Blood Pressure Hepatitis A Hepatitis B Hepatitis C Kidney Disease Liver Disease Jaundice Mental Disorders Psychiatric Care Nervous Disorders Pregnancy Due date: PCOS(Polycystic Ovarian Syndrome) Respiratory Problems Asthma Cough, persistant Shortness of breath Rheumatic Fever Rheumatism Sinus Problems Stomach Problems Gerd Ulcers Stroke Tuberculosis Cough up blood Tumors Tobacco Habit Thyroid Problems Veneral Disease Frequent Headaches Sleep Problems CPAP Other: 6 - Have you ever had any complications following dental treatment? Yes No If yes, please explain: 7 - Have you been admitted to a hospital or needed emergency care during the past two years? Yes No If yes, please explain: 8 - Are you now under the care of a physician? Yes No If yes, please explain: 9 - Do you have any health conditions that need further clarification? Yes No If yes, please explain:

2 Please List Medications You Are Currently Taking (If you have a preprinted list, attach here) Medication Name Dosage Times per Day Reason for Taking To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail. Date: Signature of patient, parent or guardian

3 DENTAL Insurance Information Primary: Name of Insured Employee: Date of Birth: Insurance Member ID #: Insurance Company: Insurance Company Address and Phone: Insured Employer: Group #: Secondary: Name of Insured Employee: Date of Birth: Insurance Member ID #: Insurance Company: Insurance Company Address and Phone: Insured Employer: Group #: Consent for Services As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied. I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination. In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to their content. Date: Relationship to Patient: Signature of patient, parent or guardian Date: Relationship to Patient: Signature of guarantor of payment/responsible party

4 Jeffrey W. Cross D.D.S. 604 Solarex Court Suite 200 Frederick, MD Patient Name: DOB: Section 1: Epworth Sleepiness Scale Please indicate how likely you are to doze off or fall asleep in the following situations: (0=never, 1=slight, 2=moderate, 3=high chance of dozing) CIRCLE ONE RESPONSE FOR EACH QUESTION Sitting and reading Watching television Sitting in a public place As a passenger in a car for one hour Driving a car stopped for a few minutes in traffic Sitting & talking to someone Sitting down quietly after lunch without alcohol Lying down to rest in the afternoon TOTAL SCORE: Section 2: Patient Evaluation Fill in the blanks, circle one yes or no response for each question NO(0) YES(1) Height Weight BMI > or = to 30? 0 1 Neck Circumference Is it >17 (Men) or >15 (Women)? 0 1 Have you gained at least 15lbs in the past 6 months? 0 1 TOTAL SCORE: Section 3: Subjective Sleep Evaluation Please circle one yes or no response for each question NO(0) YES(1) Do you snore? 0 1 You, or your spouse, would consider you snoring louder than a person talking? 0 1 Your snoring occurs almost every night Your snoring is bothersome to your bed partner. 0 1 Do you feel in some way your sleep is not refreshing or restful? Do you wake up at night or in the mornings with headaches? Do you experience fatigue during the day and have difficulty staying awake? 0 1 Do you have trouble remembering things or paying attention during the day? 0 1 Do you have high blood pressure?. 0 1 TOTAL SCORE: Section 4: Prior Diagnosis NO(0) YES(1) Have you previously been diagnosed with sleep apnea? If YES: When were you diagnosed? (Approx mo/yr) Were you put on CPAP Therapy for treatment? Are you still using your CPAP every night? TOTAL SCORE: NOTES: (Please insert any notes for the doctor regarding snoring, sleep patterns or sleep apnea that you feel may be appropriate use back of page if necessary.) Primary Care Physician and/or Specialist Name & Phone Number: Patient Signature: Date:

5 Jeffrey W. Cross, D.D.S., P.A. Solarex Court, Suite 200 Frederick, MD (301) OFFICE POLICIES AND PROCEDURES Welcome to the office of Dr. Jeffrey Cross. We strive to treat each of our patients with respect and kindness in the most professional way possible. In order for your future appointments to run smoothly, we have outlined our financial policy below. PAYMENT- All payments are expected at the time of the visit. Our office accepts payment by cash, check, Visa, MasterCard, Discover, and Care Credit. If special payment arrangements are necessary, please call prior to the day of service. Unpaid charges in the excess of 90 days are subject to be sent to our collection agency. If my account becomes assigned to a collection agency, I agree to pay all collection agency fees, court costs, and attorney fees. I understand that all accounts with a balance over 30 days will be assessed a 1.5 percent late charge per month on the unpaid monthly balance. Initial INSURANCE- Dr. Cross is neither an agent nor an employee of the insurance company. The relationship we have is with you, our patient. We will gladly submit dental claims as a courtesy to you. If, for any reason, your insurance company does not pay/pays less than expected for services rendered by Dr. Cross and his team; then you are responsible for the remaining balance. If your carrier pays any funds in excess, you will be entitled to a refund of the credit. You are ultimately responsible for knowing and understanding your policy, its benefits, exclusions, and limitations. Initial SCHEDULING AND CANCELLATION- Appointments are made in advance by reserving the appropriate time slots to accommodate each patient in a comfortable and caring environment for their required treatment. The team spends time preparing for each appointment by verifying insurance, sterilizing, organizing, and any other necessary arrangements prior to your arrival. This ensures that we achieve the high standard of care and treatment that we pride ourselves on. Because of this, we require 24 hours notice prior to cancelling or rescheduling appointments. We encourage all patients to be on time but if you are more than 15 minutes late we reserve the right to reschedule your appointment. Patients who cancel/reschedule/no show for their appointment without proper notice will be assessed a fee. Initial RETURNED CHECKS- A fee will be charged for any checks returned for insufficient funds. This fee will be equal to the amount your bank charges for returning a check. Initial I,, hereby acknowledge that I have read and understand the please print policies stated. Signature of Patient and/or Guardian (SEAL) (Rev 01/15) Date

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7 DEBBIE THORPE Solarex Court Suite 200 Frederick MD

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