PATIENT REGISTRATION. Middle Initial: Last Name: Address: City, State, Zip: Home Phone ( ) Work Phone: ( ) Cell Phone: (_)

Transcription

1 PATIENT REGISTRATION First Name: Middle Initial: Last Name: Address: City, State, Zip: Hme Phne ( ) Wrk Phne: ( ) Cell Phne: (_) Birth Date: Age: Sex: Male r Female Scial Security Number: Occupatin: Emplyer: Address: Marital Status: Married Single Divrced Separated Widwed Spuse Name: Referring Dentist: Physician Name: Have yu ever been a patient here befre? D yu premedicate befre dental prcedure with antibitics? If s, please explain why: Respnsible party if n dental insurance: If minr patient s names: Primary Dental Insurance Infrmatin Name f Insured: Relatinship t Patient: Self Spuse Child Parent Step Parent Insured Scial Security Number: Insured Birth Date: Emplyer: Dental Insurance Name: Secndary Dental Insurance Infrmatin: Name f Insured: Relatinship t Patient: Self Spuse Child Parent Step Parent Insured Scial Security Number: Insured Birth Date: Emplyer: Dental insurance Name:

2 MEDICAL HISTORY Patient name: Height Weight Date f last physical exam: 1. D yu have injuries r inflamed areas, grwths r sre spts in r arund yur muth? If yes, explain. 2. Has there been any changes in yur general health within the past year? If yes, explain. 3. Are yu under the care f a physician fr a current prblem? If yes, explain. 4. Have yu ever been hspitalized within the past 5 years? Please specify. 5. Have yu received therapy fr alchlism r drug addictin during the past 5 years? 6. Have yu ever had any ALLERGIC r ADVERSE REACTIONS t anesthetics/antibitics/medicatins? 7. Is there any cnditin cncerning yur health that the dctr shuld be tld? 8. D yu wish t speak with the dctr privately abut anything? 9. Have yu had abnrmal bleeding with previus extractins, surgery, r trauma? 10. Have yu ever required a bld transfusin? 11. Have yu ever had radiatin fr any cnditin?

3 12. Have yu ever tested psitive fr HIV infectin r AIDS? Is s state date diagnsed and treating Dr. 13. Are yu required t take antibitics prir t dental treatment? 14. D yu have, r have yu had any f the fllwing? Please circle all that apply. High bld pressure Heart murmur r prlapsed valve Jint prsthesis (hip, knee, etc.) Rheumatic fever r rheumatic heart disease Cngenital heart disease Cardivascular disease: heart attack, strke bypass Prsthetic heart valve Bld disrder (e.g., anemia) Venereal disease Asthma Allergic t latex Lw bld pressure Chest pain, angina Swllen ankles, arthritis r jint disease Cardiac pacemaker Heart surgery Delay in healing Tuberculsis Emphysema X-Ray treatment r chemtherapy On a diet Histry f alchl abuse Eye disease r glaucma Infectius mnnuclesis Diabetes Thyrid prblems Sinus truble Stmach ulcers, clitis Hepatitis, jaundice, liver disease Kidney prblems Psychiatric treatment Fainting spells r seizures Epilepsy Cancer Temprmandibular jint prblems (TMJ) Lw bld sugar Dialysis Irregular heart beat Cntagius diseases Brnchitis, chrnic cugh Hay fever r sinus prblems Prblems with the immune system Difficult breathing r ther lung truble Chrnic fatigue r night sweats Histry f drug abuse Wear cntact lenses Bruise easily Gallbladder truble

4 15. Are yu taking any herbal medicine (i.e., St. Jhns Wrt)? 16. Have yu ever taken the fen-phen diet? 17. D yu have any disease, cnditin r prblem nt listed abve? Specify. 18. Are yu taking bisphsphnates nw r have yu ever taken them in the past (Fsamax)? 19. Are yu taking any medicatin r drugs? If yes, please list them belw. Medicatin start date Quantity Medicatin prescribed Reasn fr taking this medicatin Cmpletin date Wmen nly: Pssibility f pregnancy: Estimated delivery date: Nursing: Taking birth cntrl pills: Yes r N WOMEN NOTE: Antibitics (such as penicillin) may alter the effectiveness f birth cntrl pills. Cnsult yur physician/gyneclgist fr assistance regarding additinal methds f birth cntrl. Injury: This visit is related t an accident: Yes r N Wrk related: Yes r N Date f Injury: Insurance Cmpany Handling the claim: Claim number: Name f Attrney/Adjustr:

5 Attrney/Adjustr Telephne #: Physicians Infrmatin: Physician Name: Physician Phne #: Specialist Name: Specialist Phne #: Emergency Cntact Infrmatin: First name Last name Hme phne # Wrk phne # Cell phne # 20. Have yu been ut f the cuntry recently? Is s, where and fr hw lng?

6 Grandville Enddntics Yur Privacy is Imprtant t Us Acknwledgement f Receipt f Ntice f Privacy Plicies (Adults and Minrs) I have received a cpy f the Ntice f Privacy Practices f Grandville Enddntics. I hereby authrize, as indicated by my signature belw, Grandville Enddntics t use and disclse my prtected health infrmatin fr any necessary clinical, financial, and insurance purpse, as authrized in the Patient Cnsent frm. Minr s first/last name Print patients first/last name Signature Parent/guardian first/last name r legal guardian Address Date Please check yur preferred means f cmmunicatin: Yu may cntact me at my hme telephne number Yu may cntact me n my mbile telephne number Yu may cntact me n my wrk telephne number Yu may send me an at: Other frm f cntact infrmatin: Please list authrized persns with whm we may discuss yur Prtected Health Infrmatin (PHI) in additin t custdial parents and legal guardians: 1. Date Added/Remved: 2. Date Added/Remved: 3. Date Added/Remved: FOR OFFICE USE ONLY We have attempted t btain written acknwledgement f receipt f ut Ntice f Privacy Practices, but acknwledgement culd nt be btained because: Individual refused t sign Cmmunicatin barriers prhibited btaining the acknwledgement An emergency situatin prevented us frm btaining the acknwledgment Other (Please Specify) Staff Persn Initials

7 Patient Cnsent Frm Clinical: I authrize Grandville Enddntics, PC t perfrm all recmmended treatment by Dr. Licari. I authrize Grandville Enddntics, PC t take radigraphs, CBCT scans, phts, and ther diagnstic aids r materials (cllectively, Diagnstic Material as needed t make a thrugh diagnsis. I authrize that such Diagnstic Material may be released t third-party payrs and/r ther health prfessinals. I authrize the use f anesthetics, sedatives and ther medicatin, as needed, and am fully aware that using anesthetic agents invlves certain risks, including but nt limited t redness and swelling f tissue, pain, itching, vmiting, paresthesia, numbness, dizziness, miscarriage, cardiac arrest, drwsiness, and/r lack f crdinatin. Financial: I am respnsible fr payment fr all services rendered n my behalf. I understand that payment is due when services are rendered. I am aware that a 2% MPR r 24% APR autmatically may be tabulated int my accunt if my balance exceeds 90 days. Shuld my accunt becme delinquent, I understand that I am 100% respnsible fr all additinal cllectin csts, attrney fees and r curt csts. Insurance: I authrize the practice t release t staff, hspitals health care service plans, insurance cmpanies, self-insurers r their representatives, any and all infrmatin, recrds, and ther recrds, and ther diagnstic materials abut my medical histry, services rendered, r recmmended treatment. I authrize the practice t submit claims fr payment fr services rendered r pre-authrizatins necessary t my insurance cmpany, n my behalf and in my name listed as my signature n file and assign t the practice the insurance benefits prviding assignment is accepted. I understand that nt all dental insurance cmpanies cver services that Grandville Enddntics may recmmend and r perfrm and that if there is a balance it is my respnsibility t pay that balance. I am 100% respnsible fr payment regardless f cverage prvided. I have read this Patient Cnsent and agree t ALL terms and cnditins herein. Patient s Name: Date: Patient s signature: IF PATIENT IS A MINOR PARENT/GUARDIAN SIGN BELOW Patient s Name: Date: Parent/Guardian signature: Date: