Patient Information. Personal Information. Preferred name: ( ) Male ( ) Female ( ) Single ( ) Married

Transcription

1 Patient Infrmatin Welcme t Art f Dentistry! We will always d ur best t earn the trust that yu have placed in us. Please fill ut these frms. Persnal Infrmatin Patient s Full Name: f Birth: Address: Preferred name: ( ) Male ( ) Female ( ) Single ( ) Married Please check the best number t reach yu at: Cell Phne: Hme Phne: Scial Security #: Spuse s Name: Emergency Cntact Wrk Phne: Ext I can receive text messages Yes N I can receive s Yes N Emergency Phne # Hw did yu hear abut us, r whm may we thank fr referring yu? What is the name f yur previus dentist? If the patient is a minr, fill ut the fllwing infrmatin fr the parent r guardian: Name: Address: Insurance Infrmatin fr Plicy Hlder Name f Plicy Hlder: Scial Security #: Name f Insurance C: Name f Emplyer: Relatinship t Patient: Hme Phne #: Cell Phne #: I can receive texts Yes N I can receive s Yes N Plicy Hlder s f Birth: Member ID: Grup #: Effective : Plan Name r #: If yu have additinal Insurance please cmplete the fllwing infrmatin fr the Plicy Hlder: Name f Plicy Hlder: Scial Security #: Name f Insurance C: Name f Emplyer: Emplyment/Student Infrmatin Plicy Hlder s f Birth: Member ID: Grup #: Effective : Plan Name r #: Occupatin: Emplyer Name: If Student, Grade & Schl Name: Business Phne: Wrk Address: Patient s (Guardian s) Signature

2 MEDICAL HISTORY Patient Name: f Birth: : Are yu under a physician s care nw? Yes N If Yes: Have yu ever been hspitalized r had a majr peratin? Yes N If Yes: Have yu ever had a serius head r neck injury? Yes N If Yes: Are yu taking any medicatins, pills, r drugs? Yes N If Yes: D yu take, r have yu taken, Phen-Fen r Redux? Yes N If Yes: Have yu ever taken Fsamax, Bniva, Actnel r any ther medicatins cntaining bisphsphnates? Yes N If Yes: Are yu n a special diet? Yes N If Yes: D yu use tbacc? Yes N If Yes: Wmen: Are yu Pregnant/ Trying t get pregnant? Nursing? Taking ral cntraceptives? Are yu allergic t any f the fllwing? Aspirin Penicillin Cdeine Acrylic Metal Latex Sulfa Drugs Lcal Anesthetics Other? Yes N If Yes: D yu use cntrlled substances? Yes N If Yes: D yu have, r have yu had, any f the fllwing? Check any that apply AIDS/HIV Psitive Crtisne Medicine Hemphilia Radiatin Treatments Alzheimer s Disease Diabetes Hepatitis A Recent Weight Lss Anaphylaxis Drug Addictin Hepatitis B r C Renal Dialysis Anemia Easily Winded Herpes Rheumatic Fever Angina Emphysema High Bld Pressure Rheumatism Arthritis/Gut Epilepsy r Seizures High Chlesterl Scarlet Fever Artificial Heart Valve Excessive Bleeding Hives r Rash Shingles Artificial Jint Excessive Thirst Hypglycemia Sickle Cell Disease Asthma Fainting Spells/Dizziness Irregular Heartbeat Sinus Truble Bld Disease Frequent Cugh Kidney Prblems Spina Bifida Bld Transfusin Frequent Diarrhea Leukemia Stmach/Intestinal Disease Breathing Prblems Frequent Headaches Liver Disease Strke Bruise Easily Genital Herpes Lw Bld Pressure Swelling f Limbs Cancer Glaucma Lung Disease Thyrid Disease Chemtherapy Hay Fever Mitral Valve Prlapse Tnsillitis Chest Pains Heart Attack/Failure Osteprsis Tuberculsis Cld Sres/ Fever Blisters Heart Murmur Pain in Jaw Jints Tumrs r Grwths Cngenital Heart Disrder Heart Pacemaker Parathyrid Disease Ulcers Cnvulsins Heart Truble/Disease Psychiatric Care Venereal Disease Yellw Jaundice Other serius illness nt listed abve: T the best f my knwledge, the questins n this frm have been accurately answered. I understand that prviding incrrect infrmatin can be dangerus t my (r patient s) health. It is my respnsibility t infrm the dental ffice f any changes in medical status. Signature

3 Financial Plicy It is ur gal t keep prices as lw as pssible. If yu have insurance, we will file it fr yu. If yu d nt have insurance, we accept cash and all majr credit/debit cards. We will accept checks nly frm established patients. Regarding Insurance: Yur insurance plicy is a cntract between yu and yur insurance cmpany. We are nt a party t that cntract. We accept assignment f insurance benefits after yu furnish us with yur full insurance infrmatin and this is verified by yur insurance carrier. Yur deductible and patient prtin are due at the time f service. Sme f the services prvided may be a nn-cvered service and nt cnsidered necessary by yur dental carrier. Yu are respnsible fr payment f any insurance cmpany s arbitrary determinatin f usual and custmary rates. If the patient is a minr, the adult accmpanying a minr patient is respnsible fr payment in full. Assignment f Insurance Benefits: I hereby authrize payment directly t Art f Dentistry and its dental prviders fr the dental service benefits therwise payable t me. I understand that, althugh Art f Dentistry will d all that is in their pwer t present t me estimates that are as accurate as pssible, any qute given t me, in persn, in writing, ver the phne, r in any frm f cmmunicatin used by Art f Dentistry will nly be an estimate based n the infrmatin prvided t them by my insurance carrier. I understand that if perfrmed dental services are nt under cntract with my insurance carrier r I have met my cntract limitatins, I am respnsible fr payment f the full balance due. Missed Appintments: We ask that yu give us 24 hurs advance ntice fr any cancelled appintment. Once tw scheduled appintments have been missed withut the request advance ntificatin, we will require yu t pay fr the appintment in advance befre we can schedule yu anther appintment. We reserve the right t deny any future scheduling f appintments due t repeatedly missed, cancelled, r late appintments. Unpaid Balances: If yur accunt becmes past due, we will take necessary steps t cllect this debt. I understand that any attrney fees, curt csts, and cllectin fees becme my respnsibility and will be added t my accunt, shuld it becme necessary. Returned checks will be subject t a $25.00 fee per ccurrence. Finance charges f 1.5% per mnth will be impsed n the unpaid balance after yur accunt has gne 30 days past due. Credit Histry: If yur accunt were t becme past due, we have the ptin t check yur credit histry and t reprt yur accunt histry t any credit reprting agency such as a credit bureau. I have read the Financial Plicy and I understand and agree t this plicy. Signature

4 ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRIVACY PRACTICES Art f Dentistry 5913 Main St., Suite 101 Oltewah, TN Acknwledgement I,, hereby acknwledge that I have been given the pprtunity t review a cpy f Art f Dentistry's HIPAA Ntice f Privacy Practices. I understand that Art f Dentistry's HIPAA Ntice f Privacy Practices may change peridically and that I am entitled t receive a cpy f Art f Dentistry's revised HIPAA Ntice f Privacy Practices upn request. I understand that, if I have questins abut Art f Dentistry's HIPAA Ntice f Privacy Practices, I may cntact Heidi Lpez at I understand that it is my right t refuse t sign this Acknwledgement shuld I s chse, and that Art f Dentistry will nt refuse treatment t me if I refuse t sign this Acknwledgement. I further understand that I may cntact the Secretary f the U.S. Department f Health and Human Services shuld I have cncerns regarding Art f Dentistry's privacy plicies and prcedures. Patient Signature Signature f Guardian (if patient underage) Print Name f Guardian Relatinship t Patient FOR OFFICE USE ONLY Art f Dentistry made a gd-faith effrt t btain Acknwledgement, frm the patient nted abve, f receipt f its HIPAA Ntice f Privacy Practices. In spite f these effrts, Art f Dentistry was unable t btain a signed Acknwledgement fr the fllwing reasn(s): Refusal t sign Acknwledgement n, 20. Cmmunicatins barriers prhibited us frm btaining a signed Acknwledgement. An emergency situatin prhibited us frm btaining a signed Acknwledgement. Other (Describe): Received By Patient ID

5 Media Release Frm I,, hereby cnsent that phtgraphs and/r vide pictures can be taken f me and used by Art f Dentistry r any authrized agent f Art f Dentistry fr the fllwing purpses: Fr inclusin in my dental recrds. Yes N Fr any purpse f illustratin, teaching, publicatin in dental jurnals, r fr any ther dental purpse deemed apprpriate by my dentist. Yes N Use n scial media sites t demnstrate final utcmes. Yes N Law enfrcement requests. Yes N Publicity r ad campaigns. Yes N Signature