Aristidis Pontikas, D.M.D., M.S.,P.L.L.C. Medical/Dental History Name: First, Middle, Last Sex Birth Date Marital Status Email Address Street Address City State Zip Social Security Number Home Phone Daytime/Work Phone/ext Cell Phone Employer s Name & Address Person Responsible For Payment of Account Relation Phone H) W) Dentist s Name, Phone Number, Address Referred to This Office By: In Case of Emergency Contact- Name and Phone Number Preferred Hospital Primary Dental Insurance Company Subscriber s ID or Social Security Number Subscriber s Name Subscriber s DOB Group or Company Name Group Number Secondary Dental Insurance Company Subscriber s Name Group Number Patient s Relationship to Subscriber- self* spouse* child Subscriber s ID or Social Security Number Group or Company Name Patient s Relationship to Subscriber- self* spouse* child Medical Doctor s Name Address Phone # and Fax # My Last Physical Examination was on (Date) Results Are you under the care of your physician? If, for what reason? Are you taking any medication at the present time (including Aspirin or Coumadin or Birth Control Pills)- PLEASE LIST THEM HERE: Are you sensitive or allergic to any medication? If yes, list reasons and dates: Have you ever been hospitalized, had any surgical operations, or blood transfusions? If, list reasons and dates: Have you ever had implants, transplants, or joint replacements? If yes When? Are you now, or have you ever taken medication for osteoporosis? If yes, which one and for how long? Do you currently or have you had: No High Blood Pressure No Phen Phen/Redux No Asthma No Psychiatric Treatment No Mitral Valve Prolapse No Ulcers No Chemotherapy (cancer) No Radiation Treatment No AIDS No Low Blood Pressure No Stroke- Date No HIV + No Multiple Sclerosis No Thyroid Disease No Fibromyalgia No Tuberculosis No Angina Pectoris No Lupus No Rheumatic Fever No Fainting or Dizzy Spells No Osteoporosis No Scarlet Fever No Kidney Disease No Pacemaker No Heart Murmur No Allergies or Hives No Nervousness No Heart Disease No Venereal Disease No Anemia No Gall Bladder Disease No Epilepsy or Seizures No Arthritis No Joint replacement No Bladder disease No Hepatitis No Smoking/Tobacco use No Heart Attack -Date No Diabetes
No Do you have shortness of breath after mild exercise? No Do you use extra pillows to sleep? No Do your ankles swell? No Do you bruise easily? No Have you ever had yellow jaundice? No Do you have to urinate(pass water) more than 6 times a day? No Are you thirsty much of the time? No Does your mouth frequently become dry? No Have you lost or gained weight(more than 10 pounds) in the past year? No Are you following a diet? No Do you have cataracts or glaucoma? No Do you have difficulty in swallowing? No Has a doctor ever said you have cancer or a tumor? No Have you ever had excessive bleeding from a cut or wound? No Do you have frequent or severe headaches? No Do you worry a great deal? No Are you under abnormal stress? (for example, marital, business or social) No Do you feel you need psychiatric care or advice? No Do you sometimes take medication to relieve nervousness? No Do you have any disease, condition, or problem not listed above? If yes please explain: No Have you had any serious trouble associated with any previous dental treatment? If yes, explain: No Do you bleed excessively after a tooth extraction? No Have you had dental x-rays recently? If yes, when: No Have you had undesirable reactions to local or general anesthetics? (for example, Novocain or gas) No Do you clench or grind your teeth? No Are any of your teeth sensitive to cold or sweets? No Are you dissatisfied with the appearance of your teeth? No Have you had excessive swelling or pain after oral surgery? No Have your teeth been cleaned recently? If yes, when: No Do you have bleeding gums? No Do you have a bad taste in your mouth? No Does food pack between your teeth? No Do you have pain with chewing? No Does your jaw click or pop when you chew? No Have you ever received treatment for periodontal disease? No Has a dentist ever ground on your teeth to correct your bite? No Are you willing to become actively involved in the treatment of your periodontal disease? Briefly state your feelings toward dentures: What is your chief complaint concerning your mouth or teeth? Females: No Do you have trouble with your periods? (If you do not menstruate, answer no.) No Did you have any complication during pregnancy (If you haven t been pregnant, answer no.) No Are you pregnant? Date of delivery: No Are you taking oral contraceptives (Birth control pills)? To the best of my knowledge all of the above answers are true and correct, if I have any change in my health, I will inform Dr. Aristidis Pontikas at my next appointment. Signature of Patient Date
Aristidis Pontikas, D.M.D., M.S., P.L.L.C. Release and Financial Responsibility Agreement I understand that I am personally responsible for complete payment of all services, treatments, and products at the time dental services are rendered unless, financial arrangements have been made prior to consultation and presented to me in writing, bearing signature of authorized personnel within the practice of Dr. Aristidis Pontikas. I understand where appropriate, credit reports may be obtained, to facilitate payment arrangements if so desired. I hereby authorize payment directly to Dr. Aristidis Pontikas for dental benefits if any, otherwise payable to me for any services provided. I understand that I am financially responsible for any charges/fees not covered by my dental insurance provider. I further understand that any co-payments or monies paid toward dental treatments/procedures performed in the facility is ONLY AN ESTIMATE, and actual amounts owed will be determined at the time dental insurance claims payments have been paid in full. In the event of default on my behalf of this agreement, I agree to pay interest, legal fees, collection costs, and attorney fees incurred as a result of nonpayment. I understand that if the entire balance on my account is not paid in full within (30) calendar days after receipt of notification of delinquency, finance charges will be assessed, and my account with Dr. Aristidis Pontikas will be adjusted to reflect the aforementioned. I understand that it is my responsibility to update my records at Dr. Aristidis Pontikas office in the event of any address, phone number or insurance changes immediately. I will be held liable for any repercussions as a result of my failure to report such changes. I understand that I will provide Dr. Aristidis Pontikas with notification at least one week prior for surgical procedures or a $200.00 per appointment hour missed appointment fee may apply, and two business days prior for non-surgical appointments or a $100.00 per appointment hour missed appointment fee may apply to any cancellations and/or rescheduled appointments other than emergencies. I hereby authorize Dr. Aristidis Pontikas to release any information acquired in the course of examination or treatment to my insurance carrier or other dental/medical professionals. Patient/Guardian Signature (Required if a minor) Staff signature/witness Date
Aristidis Pontikas, D.M.D., M.S., P.L.L.C. Consent for use and disclosure of health information Purpose: In cases where Dr. Aristidis Pontikas as directed not to rely on acknowledgements as a basis to use or disclose health information, this form is used to obtain a patient s consent to use and disclose the patient s protected health information to carry out treatment, payment activities, and healthcare operations, as described more fully in our Notice of Privacy Practices. SECTION A: PATIENT GIVING CONSENT Name: Address: Telephone: E-mail Social security # SECTION B: TO THE PATIENT- PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY. Purpose of consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice is available upon request. We encourage you to read it carefully and completely before signing this consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices including any revisions of our Notice, at any time by contacting: Contact Person: Sunny, or Dr. Aristidis Pontikas 301 East Bethany Home Road, Suite B-120 Phoenix, Arizona 85012 Telephone (623) 934-1676 Fax (623) 934-6630 Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this consent. Signature I, have had full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations. Signature: Date: If a personal representative on behalf of the patient signs this consent, complete the following: Personal Representative s Name: Relationship to Patient: YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT. Include completed consent in the patient s chart.
Aristidis Pontikas D.M.D., M.S. Dental Implants and Periodontal Health Patient-Provider Guidelines and Responsibilities Effective April 1 st, 2009 Welcome to our practice. Your dentist or dental specialist has identified an implant and/or periodontal need in the course of your treatment and we are honored that you were referred to our practice. My team and I are dedicated to providing you the most helpful information and treatment options to meet your needs. Successful therapy outcome is based on a clear understanding of treatment need, treatment options, and post-treatment follow up care. The following items are important to understand as you start this process. Please review them carefully, initial by each and sign below. 1. We are a specialty dental office and only provide therapy and follow up care specific to our specialty. It is important that you maintain your relationship with your general dentist for regular dental care. 2. It is very important that you provide a complete medical and dental history including all existing medical conditions and all current medications you are taking. I have directed my team to periodically ask you to update this history. I thank you in advance for the time you will take to do so. It is very important that we have a clear understanding of your current medical and dental conditions as it does impact your treatment. This is in your and my team s best interest. 3. It is very important to provide accurate dental insurance information to my team so that we may help provide you with details regarding insurance coverage. This does not include medical insurance, they do not provide for dental care needs (including surgical needs). 4. It is important for you to understand your dental insurance. Dental insurance is not medical insurance. Dental insurance has not been designed to meet all of your dental care needs. It is a defined benefit allowance with limits that have not changed since 1970. Your dental insurance will only pay a portion of a particular part of your treatment, up to a maximum amount they determine. Ultimately, they will elect what amount they want to pay, if anything. Having a clear understanding of this, and of your personal insurance limits, will help you receive the treatment you need. Ultimately your teeth are your responsibility, not your insurance s.
5. My team is dedicated to helping you with your dental insurance. We make every effort to attain accurate information from your dental insurance carrier based on the information you provide us prior to your appointment regarding your coverage. We also, at no expense to you, will take time to complete the required paperwork and submit it to your dental insurance carrier on your behalf. Therefore, we require payment of any portion of your treatment cost not covered by your insurance to be paid in full at the time of service. We will follow up with your insurance company for the balance of the fee. Please be aware that if your insurance carrier denies payment the balance is your responsibility. If you feel you have a better working relationship with your insurance carrier, we will be happy to accept payment in full for your treatment and help you prepare the paperwork required by your carrier so that you may follow up with them directly for reimbursement. 6. We know that understanding dental insurance can be challenging. My team is dedicated to helping you; however, they are not responsible for the limits your insurance company provides and what procedures they do or don t cover. If you are unhappy with your current coverage please discuss that with you dental insurance provider, employer, or human resources department- not our team- as they are not responsible for your coverage options. 7. Please be aware that if your account is not paid in full within 30 days of your insurance paying their portion, a $50 collection-processing fee will be added to the outstanding balance and your account will be turned over to Arrowhead Collections, Inc. 8. My team and I value your time, and we make every effort to start your appointment promptly at the time scheduled. We will provide you with reminders prior to your scheduled appointments. We ask that you make every effort to be on time and not to change your scheduled appointment, unless absolutely necessary. Missed appointments prevent us from scheduling appropriately and keep others in need of urgent care from being seen. If patients chronically fail to appear on time and/or frequently reschedule confirmed appointments, we will be forced to terminate the provider-patient relationship. 9. Please be advised that at no time will inappropriate language be tolerated while on the premises or over the phone with any of our team members. Such behavior could justify cause for termination of the provider-patient relationship. 10. I have read and understand the above provider-patient guidelines and responsibilities and I agree to abide by these rules. Print Name Signature of Patient/Responsible Person Date