Welcomes You! Patient Information. Name: Preferred name: Male Female (Last) (First) (Mi) Home Address: (Street) (City) (State) (Zip)

Transcription

1 Welcomes You! Patient Information Today s Date: Address: I would like to receive correspondence via: text phone Name: Preferred name: Male Female (Last) (First) (Mi) Birthdate: / / Age: Social Security #: Marital Status: S M D W Home Address: (Street) (City) (State) (Zip) Home Phone #: ( ) Cell #: ( ) Work Phone #: ( ) Driver s License #: Whom may we thank for referring you? Employer: Occupation: Spouse: Name: Birthdate: / / Phone#: ( ) ER Contact (Other Than Spouse): Relationship: Phone #: ( ) Responsible Party (If other than Yourself) Name: Relationship: Phone #: ( ) Social Security #: Employer: Work #: ( ) Billing Address: (Street) (City) (State) (Zip) Dental Insurance Information Name of Insured: Insured SS#: Insured DOB: / / Insured Employer: Member ID#: Insurance Company: Phone #: ( ) Is there secondary coverage? If yes, Please provide us with the same information needed for your primary. Please give all insurance cards to receptionist for copies.

2 Dental History Understanding your dental history and experiences is very important to us. Answering these questions will help us provide the best possible dental experience! Name: Previous Dentist: Last Dental Visit? Reason for Leaving? Times per day you brush? Bristle Type: Soft Med. Hard Are you currently in pain? Y N If yes, how severe on 1-10 scale? Do you require antibiotic before dental treatment? Y N Do you floss daily? Y N Do your gums ever bleed? Y N Are your teeth sensitive to cold, hot, sweet or anything else? Y N Have you ever had periodontal (gum) disease? Y N Do you have trouble sleeping/ snore? Y N Have you ever had orthodontics (braces)? Y N Do you have any dental implants? Y N Do you clench or grind your teeth? Y N Do you have your wisdom teeth? Y N Are you interested in whiter teeth or fresher breath? Y N Overall, are you happy with the way your smile looks? Y N If not, what would you change? Additional Comments/ Concerns:

3 TIME 10:43 AM DATE 7/12/2011 MEDICAL HISTORY PATIENT NAME Birth Date 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? If yes, please explain: Have you ever been hospitalized or had a major operation? If yes, please explain: Have you ever had a serious head or neck injury? If yes, please explain: Are you taking any medications, pills, or drugs? Do you take, or have you taken, Phen-Fen or Redux? If yes, please explain: Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Are you on a special diet? Do you use tobacco? Do you use controlled substances? Women: Are you Pregnant/Trying to get pregnant? Taking oral contraceptives? Nursing? Are you allergic to any of the following? Aspirin Penicillin Codeine Local Anesthetics Acrylic Other If yes, please explain: Metal Latex Sulfa drugs Do you have, or have you had, any of the following? AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease 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 Have you ever had any serious illness not listed above? If yes, please explain: Comments: 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 Balcones Family Dental Patient Authorization Form Please read, initial and sign below (Initial) FINANCIAL RESPONSIBILITY: I understand that I am ultimately responsible for payment on my account. Payment is expected at time of service. I understand and agree that if I fail to make any of the payments for which I am responsible in a timely manner, I will be responsible for all costs of collecting monies owed, including court costs, collection agency fees and attorney fees. (Initial) INSURANCE COVERAGE: As a courtesy to our patients, we will file your insurance for you and accept payment from them with your authorization. Please te: We are NOT an in-network provider with any insurance companies. The contract is between you and your insurance company. You are responsible for deductibles and co-pays at the time of service and for any amount not covered by insurance due to coverage limitations. We will do our best to estimate your out of pocket expense, but please be aware that we are not contracted with your insurance. You are required to pay your estimated portion when services are rendered. If you choose to assign benefits to us, we will make every effort to collect from your insurance company for a period of 45 days. Once the claim falls into the 45 th day for collection, you will become responsible for any unpaid balance. Any payment arrangements needed should be made PRIOR to date of service. In the event your insurance company establishes a usual and customary fee schedule, you will be responsible for any difference remaining. If any payment is made directly to you for services billed by us, you recognize an obligation to promptly remit entire remaining balance to Balcones Family Dental. I understand that I am responsible for providing the office with any and all insurance coverage at each visit. I am responsible for any amount unpaid by my insurance. (Initial) CONSENT FOR TREATMENT: I agree and consent for Balcones Family Dental to furnish dental care and treatment considered necessary and proper in diagnosing or treating dental conditions. (Initial) RELEASE OF INFORMATION: I do hereby authorize Balcones Family Dental to release information to any specialist or dentist in the event of a referral. I authorize the release of any dental records or any other information necessary to process my insurance claim. (Initial) HIPAA: I acknowledge that I have received or have access to a copy of Balcones Family Dental s tice of Privacy Practices. Patient Name (Printed): Date: Patient (or Representative) Signature: Relationship to Patient:

5 SLEEP APNEA The following survey has been provided to aid you in diagnosing and curing issues which might be related to snoring, upper air resistance and sleep apnea. Please circle your condition during the following activities. 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing Sitting and reading Watching television Sitting inactively in a public place As a passenger in a car for an hour without break Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after lunch without alcohol Driving a car stopped in traffic or at a stop light Have you ever been told you snore? YES NO Do you wake up fatigued? YES NO Do you have morning headaches? YES NO Have you been diagnosed with chronic fatigue syndrome, fibromyalgia, or TMJ? YES NO Any additional comments that may be helpful? Print Name Signature Date