Patient s name Date Date of Birth Male [] Female [] Married [] Single [] Widowed [] Child [] Street Address City State Zip Phone: Hm Wk Cell E-mail Social Security # Spouse s name Patient employed by Referred by If minor, parent s name Person responsible for account Address, if different from above Emergency contact Relationship Phone Medical History Physician Telephone Date of last visit 1. What is your estimation of your present health? Good [] Fair [] Poor [] 2. Are you currently or have you been under the care of a physician during the past two years? Yes No 3. Have you been hospitalized during the past two years? Yes No 4. Has your doctor or dentist ever recommended that you take an antibiotic prior to dental care? Yes No 5. Have you ever had a blood transfusion? When 6. Have you ever had trouble with prolonged bleeding after surgery? Yes No 7. Have you ever had any unusual reaction to an anesthetic or drug (like penicillin?) Yes No 8. Do you use tobacco in any form? Yes No 9. Is there a possibility that you may be pregnant? Yes No Have you ever been treated for any of the following conditions or diseases? Please circle if necessary. Yes No Yes No Heart murmurs, damaged or artificial valves, congenital heart lesions, etc. Heart trouble, heart attack, angina, stroke, arteriosclerosis, heart/vascular surgery High or low blood pressure Rheumatic fever, mitral valve prolapse Bacterial Endocarditis Pacemaker Emphysema, Asthma, breathing problems Tuberculosis (TB) Epilepsy/Seizures Diabetes Hepatitis, liver trouble, jaundice, etc. Kidney transplant/dialysis Syphilis, gonorrhea, genital herpes, etc. Bleeding disorders, anemia, leukemia, etc. Drug reactions, Allergies (specify) Immune suppressed conditions, Lupus, Crohn s disease Arthritis, inflammatory diseases, etc. HIV/AIDS (positive test) Thyroid disease Drug/alcohol dependency Tumors or Cancer Chemotherapy/radiation therapy Bone marrow transplant Artificial joints/implants/shunt Steroid therapy Emotional disabilities Physical disabilities Fainting/ dizzy spells
Medications Reason for taking Side effects Dental History Please answer the following related to you dental health Yes No Yes No Have you had a toothache since our last visit? Are you having pain/discomfort between your teeth? Does food easily trap between your teeth? Do your gums bleed when you brush your teeth? Do you often have sores in your mouth? Are your teeth sensitive to sweets, heat or cold? Have you had a bad experience in a dental office? Have you ever had braces on your teeth? Have you had periodontal (gum) treatments? Do you feel nervous about having dental treatment? Do you have any clicking/popping in your jaw joint? Do you clench or grind your teeth? 1. When was your last dental appointment? 2. When did you have your last dental x-ray? 3. How often do you brush your teeth? 4. How often do you floss your teeth? I understand the need for these questions to be answered truthfully. To the best of my knowledge, the answers I have given are accurate. I also understand it is very important to report any changes or updates in my medical status. I give permission to obtain from my physician any additional information regarding my medical history needed to provide me with the best treatment possible. Patient Signature Date If you have completed this form for another person, please print your name and sign below along with your relationship to the patient. Print Relation ship Signature Date
JOSEPH SALAS D.M.D. AUTHORIZATION FOR THE USE OR DISCLOSURE OF HEALTH INFORMATION As part of your healthcare, this practice originates and maintains paper and/or electronic records describing your health history, symptoms, examinations, test results, diagnoses, treatment, any plans for future care or treatment and payment for the services or treatment we provided. We use this information to: Plan your care and treatment Communicate with other health professionals or entities who contribute to your healthcare Submit your diagnosis and treatment information for payment for the services or treatment provided to you ONLY AS PERMITTED OR REQUIRED BY FEDERAL OR STATE LAW, WE MAY USE YOUR PROTECTED HEALTHCARE INFORMATION TO DO THE FOLLOWING: To disclose, as may be necessary, your health information (including HIV+/AIDS status, drug/alcohol abuse/dependency notes and qualified mental health notes) to other healthcare providers and healthcare entities (such as: referrals to or consultation with, other healthcare professionals, laboratories, hospitals, etc.) or to others as may be required by law or court order concerning your treatment, payment and/or healthcare. To request from other healthcare entities and/or healthcare providers (i.e. doctors, dentists, hospitals, labs, imaging centers, etc.) specific healthcare information we may need for planning your care and treatment. To submit the necessary information to your insurance company(s) for coverage verification as well as the diagnosis and treatment information to your insurance company(s), other agencies and/or individual(s) for payment of our services or treatment we provided to you. To leave appointment reminders or other minimum necessary information related to your healthcare or healthcare payments on an your answering machine, mobile voice or text mail, email or with a household family member. [ ] Please check here if you do not want us to leave messages on your answering machine or with a household family member. [ ] Please check here if you do not want us to leave a message on your mobile voice/text mail. [ ] Please check here if you authorize us to send your healthcare information by email. Please understand that email is an unsecured medium of transmission and is potentially accessible by others. In addition to checking the box, we reserve the right to require you to send us an email authorizing transmission of your healthcare information to you by unsecured email.
To discuss your health or payment information (only the minimum necessary in our judgment) with family members or other persons who are or may be involved with your healthcare treatment or payments. If you choose, please list by name and relationship the persons with whom we may share your healthcare or payment information You may request a copy of and you have the right to read our Notice of Patient Privacy Practices prior to signing this authorization. The NPP provides a more complete description of health information uses and disclosures. I fully understand and agree to this authorization and acknowledge the above rights and disclosures. Patient Name (please print): - Date Signature Print name of person signing if other than patient *If other than patient is signing, are you the parent, legal guardian, legal custodian or have a Healthcare Power of Attorney for the patient. Yes [ ] No [ ] RELATIONSHIP FOR OFFICE US E ONLY Patient refused to sign the form. Reason: Date:
Joseph J. Salas, D.M.D. 3304 26 th Street W. Bradenton, FL 34205 Office (941) 708-5110 Fax (941) 708-5120 Financial Policy Insurance: Your insurance coverage is a contract between you and your insurance company. Unless we are a preferred provider for your particular insurance company, we are not affiliated with this contract. We must emphasize that, as your medical/dental care provider, our relationship is with you, not your insurance company. Unfortunately, not all dental services are considered a covered benefit. Because of our dedication to high standards of dentistry, we will not let the insurance company dictate our quality of care for you. As a courtesy to you, our office will file your insurance claims for you. However, any applicable copay and/or unmet deductibles shall be collected at the time of service. If there is a remaining balance after the insurance payment, the balance will immediately become the patient s responsibility. Our office will mail a statement to you reflecting the amount owed. As a return of that courtesy, we would appreciate remittance of the outstanding balance upon receipt of that statement. While we strive to make your dental visits financially reasonable, we also realize that outstanding accounts will have a reflection on our future fee schedule. Self-Pay: Full payment is required at the time service is rendered for those who do not have dental insurance. We do offer payment options through outside sources if you require assistance. Insufficient Funds: A fee of $30.00 will be assessed to your account if the bank renders the check as insufficient. Missed Appointments: If you cannot keep your appointment, we would sincerely appreciate notification within twenty four (24) hours of the appointment. There will be a fee of $25.00 to the patient s account for missed appointments without notice. I agree to the above policies of Dr. Joseph Salas. I authorize the release of any information, including the diagnosis and records of any treatment or examination rendered, to third party payers. I authorize and request my insurance company to make payment to Dr. Joseph Salas on my behalf. I understand and accept that I am financially responsible for any and all charges incurred for services rendered and any charges should collection proceedings become necessary. I have read and I understand the above. Printed name of Patient: Signature of Patient/Guardian: Printed name of Parent/Guardian: Date: