PATIENT INFORMATION AND MEDICAL HISTORY

Transcription

1 PATIENT INFORMATION AND MEDICAL HISTORY (Parent/Guardian) Information Seth Ardoin DDS Name Adam Coley DDS Relationship Paul Lambert DMD Social Security # Michael Zhang DDS Date of Birth Sex M / F Home Address Patient Information City/State/Zip Last Name Primary Phone First Name Secondary Phone Social Security # Work Phone Date of Birth Sex M / F address for confirming appointments Insurance Y / N Text messages Y / N *** How did you hear about us? Has your child ever been diagnosed with any of the following conditions?please check yes or no. Y N Y N Y N Anemia Congenital heart disease Heart murmur Asthma Kidney disease Hepatitis or liver disease Autism Convulsions / Seizures Hospital admission Bladder Conditions Diabetes Hyperactivity Birth defects Emotional disturbances Mental retardation Blindness Epilepsy Oral ulcers Cancer or malignancies Excessive bleeding problems Premature birth Cerebral palsy Excessive gagging Rheumatic fever Child abuse Fainting or dizziness Sickle cell anemia Chronic adenoid / tonsil Growth and Dev. Problems Snores when asleep Chronic headaches Handicap/impairments Tuberculosis Chronic ear infections Hearing / speech problems Pregnant Cleft lip/palate HIV/AIDS Other Please do not leave any questions unanswered. Use N/A if not applicable. Describe your child's previous dental experience/reactions: How long has it been since your child's last dental visit? Reason for today's visit: Recent cough/sneezing/runny nose? Y/N Please explain Name of child's medical doctor: Phone#: Is your child receiving any medication OR care from any other healthcare provider?y/n Reason for care or treatment: Has your child ever been hospitalized/surgeries? Y / N If yes, explain: List all medication or drugs your child is taking List any drug, food, latex, etc. ALLERGIES: *you may use the back for additional room on any question* Guardian Signature Date Dr. Sign Office Use Only last px

2 Abilene Pediatric Dental Associates, PLLC. Dr. Seth Ardoin, Dr. Adam Coley, Dr. Paul Lambert & Dr. Michael Zhang Patient Consent for the Disclosure of Information and Acknowledgement Form (HIPPA) I understand that by signing this form I consent to the following: 1. Sharing information for the purpose of treatment: You will share my information with all members of my treatment team, both within this office and with other providers (personal and institutional) in order to provide me with quality care and educational/wellness programs specified by my insurance plan. This will include communication with our team in verbal and non-verbal form such as postcard reminders, recognition boards, sign in information, and forms of communication for patient care and office visits. 2. Sharing information for purposes of payment: You will share all necessary information with my insurer(s), governmental entities, and their representatives (including, but not limited to benefit determination and utilization review) as well as your representatives involved in the billing process companies, and in extreme situations, credit bureaus or collection agencies. 3. Sharing of information for the purposes of operations: You will share all information necessary for ongoing operations of this office, including (but not limited to) the credentialing processes, peer review, accreditation and compliance with all federal and state laws I also understand that by signing this form, I give this office permission to leave messages on my answering machine or voic or with a relative regarding: notification of appointments, messages to call the office, test results, and any other information pertaining to you healthcare. Information may be left with: at my home or at another location. I understand that you will be unable to release ANY information to anyone other than the person/persons listed above. My consent is freely given. I understand that I may revoke this consent at any time if that revocation is in writing, but any disclosures given in reliance on this prior consent will be permissible. If you have any complaints you may contact the Texas State Board of Dental Examiners, (TSBDE), at 333 Guadalupe, Tower 3, Suite 800, Austin, TX or you can call TSBDE at Patient s Name Date of Birth TODAY S DATE Guardian Name (Please Print) Patient/Guardian Signature I have read and/or been offered/given a copy of the Notice of Privacy Practices for Abilene Pediatric Dental Associates. Parent/Guardian Initials Office Representative Name (Please Print) Office Representative Signature

3 Abilene Pediatric Dental Associates Dr. Seth Ardoin, Dr. Adam Coley, Dr. Paul Lambert, Dr. Michael Zhang GENERAL INFORMED CONSENT FOR DENTAL PROCEDURES AND ANESTHESIA This is my consent for Dr. Ardoin, Dr. Coley, Dr. Lambert, Dr. Zhang, or any other physician who may be necessary, to perform the oral, maxillo-facial, and/or dental procedures indicated on my examination chart and any other procedure deemed necessary as a corollary to the planned sedation, and/or ultra light general anesthesia depending upon the judgment of the doctors involved in my care. I have been informed and understand that occasionally there are complications that can occur with any dental procedure, including surgery, anesthesia, and or medications. These include but are not limited to the following: Post operative discomfort and swelling Heavy bleeding that may be prolonged Post operative infection requiring additional treatment Bruising or discoloration at the injection site Injury to the nerve underlying the teeth resulting in numbness or tingling of the chin, lip, cheek, gums and/or tongue on the treated site; this may persist for weeks, months, or in remote instances, permanently Stiffening of the neck and facial muscles Restricted mouth opening for several days or weeks Thrombophlebitis (inflammation of a vein) from intravenous and intramuscular injections TMJ injury secondary to treatment, especially when TMJ symptoms pre-exist Change in occlusion Injury to the adjacent teeth, restorations in other teeth, and injury to other tissues Referred pain to the ear, neck and head Nausea and vomiting, allergic reaction, cardiovascular collapse or other conditions requiring hospitalization Oral/sinus openings with delayed healing and possibly requiring additional surgery Decision to leave a small piece of root in the jaw when its removal would require extensive surgery Anesthetics, medications, and prescriptions may cause drowsiness and lack of coordination, which can be decreased by the use of alcohol or other drugs. I have been advised not to operate any vehicle or hazardous device for at least 24 hours or until fully recovered from the effect of the anesthetic or medications that may have been given to me for my care. During the course of my treatment, unforeseen conditions may be revealed that necessitate an extension of the original procedure or a different procedure than first planned. I therefore authorize and request Dr. Ardoin, Dr. Coley, Dr. Lambert, Dr. Zhang and their assistants to perform such procedures as are necessary and desirable in the exercise of their professional judgment. The authority granted under this paragraph shall extend to the treatment of all conditions that require treatment and are not known at the time the original procedure is commenced. All post operative instructions will be explained to me along with receiving written instruction. I will arrange for a post operative visit if necessary and I understand that a perfect or cure is not guaranteed or warranted and cannot be guaranteed or warranted. I also understand that I may ask for a full recital of all possible risks attendant to phases of my care by just asking. If you have any complaints you may contact the Texas State Board of Dental Examiners, (TSBDE), at 333 Guadalupe, Tower 3, Suite 800, Austin, TX or you can call TSBDE at Patient Name: Date of Birth: Today s Date: Guardian Name (Print) Patient/Guardian Signature Office Rep Name (Please Print) Office Rep Signature

4 Abilene Pediatric Dental Associates 4741 Buffalo Gap Rd. Abilene, TX RELEASE OF CONSENT FOR TREATMENT Patient or Patient s Name(s): Date(s) of Birth I understand that by signing this form I consent to the following: Notification by Dr. Ardoin, Dr. Coley, Dr. Lambert, Dr. Zhang for changes in my child s treatment and information may be left with: Name Address City State Zip Phone number Name Address City State Zip Phone number I understand that you will be unable to release ANY information to anyone other than the person/persons listed above. I authorize the Temporary Guardian, in the event that I cannot be contacted or if any urgency dictates, to act in loco parentis for the Child in respect of any circumstances, including any accident or illness, which may necessitate medical treatment, including surgery, and on my behalf to authorize any such treatment or surgery which they, in their sole discretion, (which discretion shall not be unreasonably exercised), may deem necessary. Medical treatment for the Child may also include dental surgery, x-ray, blood transfusion, anesthetic and medication provided any such medical treatment is performed by a duly licensed practitioner. I hereby accept full liability for all costs incurred through such medical treatment for the Child. My consent is freely given. I understand that I may revoke this consent at anytime if that revocation is in writing, but any disclosures given in reliance on this prior consent will be permissible. Parent/Guardian Name (Please Print) Parent/Guardian Signature Date If more room is needed, please use blank areas on this form.

5 Policy Regarding Insurance Assignment Abilene Pediatric Dental Associates PLLC Our office is pleased to accept your insurance. We offer this service as courtesy to our patients. However, it must be clearly understood that the contract is between the patient and the insurance company, the account hereby being the responsibility of the patient for any amount not paid by the insurance company. Following is a statement of our policies governing insurance claims: 1. Although our office does bill the insurance company, it is necessary for the patient to have all of the insurance information forms filled out completely. If this is not completed, we will not be able to appropriately bill the insurance company, and the responsibility for payment then becomes that of the patient. We are sorry, but there are NO EXCEPTIONS to this policy. 2. Our office will only bill your primary insurance company under any contractual limitations governing this process. We do not recognize or file to any secondary insurances. 3. We require our patients to sign an Authorization to Pay the Doctor form (or any other necessary documents required by your insurance company). By doing so, the insurance company will make payment directly to our office. 4. The patient will pay all co-payments and deductibles (the amounts not covered by the insurance company) as agreed upon during the financial consultation. 5. Insurance payments ordinarily are received within days from the time of billing. If a patient s insurance company has not made payment to our office within 60 days, we will request the patient to pay the balance due. If and when the insurance company sends payment, the patient will be reimbursed. 6. Our office does not guarantee that the patient s insurance company will pay. We will perform our routine insurance billing procedures upon verification of coverage. However, if for some reason, the patient s insurance claim is denied, the patient is then considered to be responsible for the full amount of the bill. 7. Our office will not enter into a dispute with an insurance company over any claim; however, we will work with the insurance company to sort out any confusion or questions which might arise. We cooperate fully with the regulations and requests of the insurance companies. If any dispute arises over payment by the insurance company, it will be the patient s responsibility to handle this dispute. 8. If you have any complaints you may contact the Texas State Board of Dental Examiners, (TSBDE), at 333 Guadalupe, Tower 3, Suite 800, Austin, TX or you can call TSBDE at IF YOU UNDERSTAND AND AGREE WITH ALL OF THE ABOVE POLICES, PLEASE SIGN YOUR NAME BELOW AND WE WILL ACCEPT YOUR INSURANCE. Patient Name: Date of Birth: Guardian Name (Please Print) Patient/Guardian Signature Date 5