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1 CHART NO. Welcme t DHC! :) Welcme t ur ffice. We appreciate the cnfidence yu have placed in us t prvide yu with ral health services. T assist us in serving yu, please cmplete the fllwing frm. The infrmatin prvided is very imprtant t yur verall health. If yu have any questins, please dn't hesitate t ask. 1. NEW PATIENT INFO Persnal Infrmatin Name DOB / / Age Sex Cellphne Hme Phne Emplyer Wrk Phne Driver s License State SSN Respnsible Party (leave blank if same as infrmatin abve) Name DOB / / Age Sex Cellphne Hme Phne Emplyer Wrk Phne Relatinship t patient SSN Dental Insurance (please prvide card s we may scan it int yur patient file) Insurance Prvider Grup Name Subscriber DOB / / ID #: Grup ID Phne Number Secndary Insurance Grup Name Subscriber DOB / / ID #: Grup ID Phne Number Medical Insurance (please prvide card s we may scan it int yur patient file) Insurance Prvider Grup Name Subscriber DOB / / ID #: Grup ID Phne Number Page 1 f 8
2 Dental Health Clrad Secndary Insurance Grup Name Subscriber DOB / / ID #: Grup ID Phne Number Emergency Cntact(s) Name Phne Relatin Name Phne Relatin Hw Did Yu Hear Abut Us? (please select all that apply) Online Friend Dctr Other Surce? Name? Name? Details? Page 2 f 8
3 Dental Health Clrad 2. PATIENT HEALTH HISTORY Oral Health Histry Date f Last Dental Visit / / Date f Last Medical Visit / / Name f Previus Dentist Phne Number **** PLEASE ANSWER (Y)ES OR (N)O TO THE QUESTIONS BELOW **** Are yu apprehensive abut ral treatment? If yes, please explain (minimal, mderate, severe, etc.) If 18 years f age, r lder, are yu interested in CBD t alleviate yur anxiety during yur visit? Yes N Have yu had prblems with previus ral treatment? Hw ften d yu brush? Flss/Waterpick? D yu gag easily? D yu wear dentures/partial? Des fd catch between yur teeth? D yu have difficulty chewing yur fd? D yu nly chew n ne side f muth? D yu avid brushing any side due t pain? D yur gums bleed easily? D yur gums feel sre/tender? Have yu nticed slw healing sres in muth? D yu take fluride supplements? D yur gums bleed when flssing and/r waterpicking? Are yu unhappy with appearance f teeth? D yu want t save yur teeth? D yu want cmplete ral health care? D yu use tbacc? Des yur jaw make nise? D yur jaws ever feel tired? D yu clench r grind yur jaws? Des yur jaw ever lck? Des it hurt when yu pen wide? D yu have earaches r ear pain? D yu have headaches when awaking? Des jaw pain affect yur appetite, sleep, daily rutine r ther activities? Des jaw pain cause depressin? D yu take medicatin fr pain/discmfrt (pain reliever,, muscle, relaxants)? D yu have temprmandibular jaw (TMJ) disrder? D yu have pain in face/cheeks? D yu have an uncmfrtable bite? Have yu had trauma t jaw? Are yu a habitual gum chewer? D yu have any disease, cnditin r prblem nt mentined abve? Please explain Please add anything else yu wuld like us t knw abut Please list all medicatins yu are taking (use additinal sheet if necessary) Page 3 f 8
4 Dental Health Clrad Medical Health Histry Primary Care Physician (PCP) Practice Name Specialty (if nt PCP) Preferred Hspital System Physician/Practice Hw wuld yu describe yur general health? Gd Fair Pr Are yu currently being treated r have been treated within the last year by a physician? If yes, please explain Have yu had a majr illness r been hspitalized within the last 5 years? If yes, please explain Please check if yu are sensitive r allergic t any f the fllwing: Penicillin Demerl Other Antibitic Cdeine Nvcaine r Other Dental Anesthetic Aspirin Barbiturates (sleeping pills, sedatives) Sulfa Drugs Are yu n a special diet, r have dietary restrictins? Fds (please explain) Other (please explain) If yes, please explain D yu drink alchlic beverages? Yes N Please check if yu have ever had any f the fllwing: Heart Disease Nervus Disrder r Psychiatric Care Kidney Disease r Infectins Heart Attack Ulcers Diabetes Strke Hepatitis, Liver Disease r Jaundice Bld Disrders (Anemia, Leukemia, etc.) Heart Murmur Artificial Transplants r Implants (Pacemaker, Heart Valve, Hip Jint, etc.) Hemphilia Rheumatic Fever Venereal Disease Scarlet Fever Eye Disease (Glaucma, Cataracts, etc.) Skin Disease Abnrmal Bld Pressure (high/lw) Ear Truble X-Ray, Radium r Cbalt Treatment Severe r Frequent Headaches Sinus Truble Tumrs r Malignancies Fainting Spells Lung Disease (T.B., Emphysema, etc.) AIDS Epilepsy Arthritis Other WOMEN ONLY Are yu Pregnant? N Yes Delivery Date Taking ral cntraceptives? N Yes Are yu r have yu passed thrugh Menpause? N Yes Is there any ther infrmatin abut yur health which might be imprtant fr us t knw? If yes, please explain Page 4 f 8
5 Dental Health Clrad I understand the abve infrmatin (Sectins 1 and 2) is necessary t prvide me with ral care in a safe and efficient manner. I have answered all questins t the best f my knwledge. Shuld further infrmatin be needed, yu have my permissin t ask the respective ral care and/r medical care prvider r agency, which may release such infrmatin t yu. I will ntify DHC f any change in my health r medicatin. Print Patient Name Patient/Guardian Signature X Tday s Date / / Relatinship t Patient FOR OFFICE USE ONLY Health Histry and Ntes Reviewed By Clinical Staff Dentist Date / / Hygienist Date / / Page 5 f 8
6 Dental Health Clrad 3. LEGAL STATEMENTS Releases I authrize DHC dentists and/r hygienists t perfrm diagnstic prcedures and/r treatment as may be deemed necessary fr prper ral care. I authrize release f any infrmatin cncerning my (r my child s) healthcare, advice, and treatment t anther dentist and/r physician. I authrize DHC and/r its agents t transmit patient billing and/r insurance infrmatin t my insurance carrier electrnic cmmunicatin address in lieu f U.S. Pstal Service. I authrize DHC t cmmunicate thrugh the use f electrnic mail and text messages fr: appintment reminders; bills and ther financial infrmatin; unfinished treatment plans which may cntain infrmatin related t health issues identified by DHC during previus appintments; and any ther infrmatin related t my ral care treatment that DHC believes necessary. I have the address and cellphne number listed in this frm fr that purpse. I understand that it is my respnsibility t ntify DHC when my address changes as sn as is practical. I understand that and text messaging is being used fr my cnvenience and privacy and imprved efficiency in cmmunicating with DHC. I will nt hld DHC respnsible fr disclsures that ccur due t ther individuals reading s and/r text messages sent t the address prvided belw. I understand that my dental care insurance carrier r payer f my dental benefits may pay less than the actual bill fr services. I understand that I am financially respnsible fr payments in full fr my dental accunt at time f service. By signing this frm. I agree t be respnsible fr payment f services nt paid, in whle r in part, by my dental plan payer. DHC is authrized t prvide any insurance cmpany, administratr, and cnsulting health care prfessinal, infrmatin cncerning health care advice, treatment r supplies prvided. This infrmatin will be used fr die purpse f evaluating and administrating claims fr benefits. This authrizatin is valid fr the tenure f cverage by the plicy r cntract in frce n this date nly. I knw I have the right t receive a cpy f this authrizatin upn request and agree that the phtcpy f this authrizatin is as valid as the riginal. I hereby authrize payment directly t DHC f the ral care benefits therwise payable t me. Financial Obligatins Specific Charges That Apply T Yu, the Patient Cleanings (nt all cleanings are free) Cleanings that are cvered 100% under yur ral care plan are rutine/simple cleanings nly. Rutine means abve the gum line. Patients wh have tartar, plaque, r buildup under the gum line require a different, mre invlved cleaning prcedure. There is a cmpletely different billing cde and charge fr these types f cleanings, and yur ral care plan may, r may nt, cver it. Mst patients wh have nt been examined by DHC fr mre than six mnths require mre than a rutine cleaning. It is nt apprpriate fr us t perfrm a rutine cleaning and leave the debris under the gums. Prfessinal treatment standards require yur DHC dental hygienist r dentist t clean prperly under the gum line in rder t restre yur ral health. We encurage yu t ask yur DHC hygienist r dentist after yur cmplete examinatin which type f dental cleaning will be necessary t address yur ral care. We Are a Mercury-Free Office We believe that mercury is a txic substance that shuld nt be put in yur muth. Therefre, we d nt prvide amalgam fillings that cntain mercury. DHC fillings are made f cmpsite, mercury-free materials. Sme insurance cmpanies will nly partially cver cmpsite fillings in psterir teeth. We strngly believe that keeping yur bdy free frm txic materials like mercury is wrth the small difference in yur c-pay fr cmpsite fillings. Page 6 f 8
7 Dental Health Clrad Anxiety Management We understand that visiting a dental ffice can cause anxiety, s we ffer CBD at $5 per drpper fr patients that chse t use it during their visit. Unfrtunately, this is nt yet cvered by insurance in the State f Clrad. Prbitic Treatment We ffer an ral prbitic regimen that is used t facilitate ptimal ral health and wellness. Unfrtunately, this is nt yet cvered by insurance in the State f Clrad. Financial Plicy We want t avid any misunderstanding abut ur financial plicy as it relates t yur respnsibility fr yur accunt. Please read the fllwing infrmatin and be sure t cntact DHC staff with any questins yu may have. If yu have dental and/r medical insurance, we are glad t help yu btain the apprpriate benefit frm yur insurance carrier and bill them as a curtesy t yu. Hwever, yu are respnsible fr the payment f yur accunt. We accept cash, check, mney rder, and credit cards (Visa and MasterCard nly). Prtins f yur bill might nt be paid by the insurance carrier and must be paid by yu. Any insurance deductible r c-payment required by yur insurance carrier is due at the time services are rendered. If yu d nt have insurance cverage r if yu have a managed care r a discunt plan, payment is due at the time services are rendered; unless ther arrangements have been made prir t yur appintment. If yur treatment plan requires a high ut-f-pcket expense t yu, ur ffice manager can assist yu in arranging financing r a payment schedule. If yu fail t keep yur scheduled appintment r cancel yur appintment withut 24 hurs ntice, yur accunt will be charged a $40.00 brken-appintment charge. Insurance claims are prcessed t the insurance cmpany ne time fr yur cnvenience. If the claim requires additinal prcessing there is a $25.00 claim prcessing fee each additinal time the claim is prcessed. Prblems with incmplete, incrrect, and/r wrng insurance infrmatin that delay the billing prcess and yur treatment will incur a $50.00 fee fr the crrectin and reprcessing f yur accunt. Additinal Terms Balances unpaid after 30 days frm the date f billing are subject t a cmpund interest rate f 1.5% per mnth (18% per annum). Accunts referred t cllectins will have cllectin csts added in the amunt f 30% f the utstanding balance, tgether with curt csts and reasnable attrney's fees. HIPAA Cnsent I understand that I have certain rights t privacy regarding my prtected health infrmatin. These rights are given t me under the Health Insurance Prtability and Accuntability Act f 1996 (HIPAA). I understand that by signing this cnsent I authrize yu t disclse and use prtected health infrmatin t carry ut: treatment (including direct r indirect treatment by ther healthcare prviders invlved in my treatment); btaining payment frm third payers (e.g. my insurance cmpany); and The day-t-day healthcare peratins f yur practice. I have als been infrmed f, and given the right t review and secure a cpy f yur Ntice f Privacy Practices, which cntains a mre cmplete descriptin f the uses and disclsures f my prtected health infrmatin, and my rights under HIPAA. I understand yu reserve the right t change the terms f this ntice frm time t time and that I may cntact DHC at any time t btain the mst current cpy f this ntice. I understand that I have the right t request restrictins n hw my prtected health infrmatin is used and disclsed t carry ut treatment, payment, and healthcare peratins, but that DHC is nt required t agree t these restrictins. Hwever, if DHC des nt agree, yu are then bund t cmply with this restrictin. I understand that I may revke this cnsent in writing, at any time. Hwever, any use r disclsure that ccurred prir t this date I revked this cnsent, is nt in effect. Page 7 f 8
8 Dental Health Clrad 4. ACKNOWLEDGEMENT Patient r Respnsible Party I acknwledge that I have read the abve infrmatin (Sectins 3 and 4) and have had the pprtunity t ask questins abut its cntent. I accept full legal and financial bligatin fr the services that I agree t receive as recmmended by the ral care prfessinals at DHC. Print Patient Name Patient/Guardian Signature X Tday s Date / / Relatinship t Patient THANK YOU FROM YOUR DHC TEAM! Here s t cntinued ral health and wellness! FOR OFFICE USE ONLY DHC Intake Staff Signature X Tday s Date / / Page 8 f 8
STOUGHTON DENTISTRY PATIENT INFORMATION INSURANCE INFORMATION ADDITIONAL INSURANCE INFORMATION
PATIENT INFORMATION Patient Last Name: First: MI Preferred Name: Sex: M F Birth Date: Marital Status: Scial Security N.: Street Address: City: State: Zip: Hme Phne: Wrk: Cell: Email: Preferred Cntact Methd:
Patient Information. Child s Name Birthdate Gender M F. Nickname SS# Responsible Party Name Relationship
Patient Infrmatin Date Child s Name Birthdate Gender M F Nickname SS# Respnsible Party Name Relatinship Address, Email address Hme Phne Cell Phne Wrk Phne Name f Schl Hbbies Whm may we thank fr referring
Main Phone #: ( ) - Secondary Phone # :( ) -
Patient Infrmatin Email: Male r Female: SS# - - DOB: / / Address: Main Phne #: ( ) - Secndary Phne # :( ) - (Circle One): Married Single Divrced Widwed Name f Spuse r Guardian: In Case f Emergency: Whm
SCARLET DENTAL, KATIE VINCER SEARS DDS, INC. Tel:
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Welcome to The Kids Dentist NEW PATIENT FORMS
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CONSENT FOR TREATMENT
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Patient Information. Personal Information. Preferred name: ( ) Male ( ) Female ( ) Single ( ) Married
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Bernard W Lynch, DMD, FAGD
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