**Parent/Guardian Information for Minor Children. Information for Military Members. Referral Information
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- Oswin Carter
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1 Patient Infrmatin Tday s date: Patient Name: I prefer t be called Last First MI Address: Street Apartment # City State Zip Cde Sex: Male Female Check ne: Minr child** Single Married/Partnered Patient s Date f Birth Scial Security #: Phne (Hme): (Cell) Wrk phne: ext Emplyer: Occupatin: Wrk Address: Street City State Zip Cde address: Driver s License: State # In case f emergency, please cntact: Phne: **Parent/Guardian Infrmatin fr Minr Children Parent/Guardian s name Relatinship t child Address, if different frm abve Phne (Hme): (Cell) Wrk phne: ext Infrmatin fr Military Members Spnsr s name Date f Birth Scial Security # Phne: Unit/Unit Address Wrk phne Referral Infrmatin Whm may we thank fr referring yu t ur practice? Anther patient** Our Website Yellw Pages Anther dentist Internet Search Insurance Cmpany Website TV cmmercial Suth MS Living Magazine Mississippi Magazine Other **Name f persn r ffice referring yu t ur practice:
2 Authrizatin and Cnsent General Cnsent fr Treatment I agree and cnsent t a dental examinatin/treatment by Dr. Graftn Teets, DDS. I als understand that additinal diagnstic prcedures and treatment may be recmmended and will be discussed with me befre being dne. I acknwledge that there are n guarantees, expressed r implied, as t the results f any prcedures r dental treatment. Release f Infrmatin I authrize Dr. Graftn Teets, DDS under the name Bilxi Family Dental Care t release any infrmatin regarding my dental/medical histry, diagnsis r treatment t third party payers and/r ther health prfessinals. Assignment f Insurance Benefits I authrize and request my insurance cmpany t pay my benefits directly t Dr. Graftn Teets, DDS under the name Bilxi Family Dental Care. Phtgraphy Release I authrize Dr. Graftn Teets, DDS under the name Bilxi Family Dental Care t take phtgraphs f me t help me better understand my current dental cnditin and pssible treatment ptins. I als authrize him t shw these phtgraphs t ther patients t better explain their treatment ptins (as yu may be shwn phtgraphs fr the same reasn). Appintment Plicy/Financial Plicy (Please see yur cpy fr details.) Appintments: We will cntact yu at least 48 hurs in advance t cnfirm yur appintment. Please call the ffice r respnd via text r t cnfirm yur appintment. We may nt be able t hld yur appintment time if we are unable t cnfirm yur appintment. We ask fr 48 hurs ntice t reschedule r cancel an appintment. Multiple n-shw r late cancellatins may result in an additinal charge. We cannt accept a cancellatin/rescheduling request via text message r . Financial Plicy: Payments including insurance cst shares are due at the time f service. Please see the Financial Plicy fr details n insurance, verdue accunts and payment plans. My signature acknwledges that: I have read and understand the ffice plicy regarding appintments. I have read and will cmply with the ffice Financial Plicy. I understand and agree t the General Cnsent t Treatment. I authrize the Release f Infrmatin. I assign my insurance benefits t Bilxi Family Dental Care. Phtgraphs taken f me may be shwn t ther patients. I have been ffered a chice t read r receive a cpy f the Ntice f Privacy Practices. I understand that I must give 48 hurs ntice t cancel r reschedule an appintment. I understand that multiple rescheduled r cancelled appintments may result in an additinal charge (minimum $50) that wuld need t be paid prir t scheduling future appintments. Signature f Patient, Parent r Guardian Date
3 Dental Histry Date f Last Dental Visit: What is the reasn fr tday s visit: check-up/cleaning pain/swelling Other: Are yu experiencing any f the fllwing symptms? Sensitive teeth Sre jaw Tthache Dry muth Bleeding gums Difficulty chewing Receeding gums Bad breath Burning sensatin Abcess Difficulty swallwing Sinus prblems Muth breathing Cheek biting Sre gums Calculus/tater build up Migraines Headaches neck pain Clenching/Grinding ear pain Have yu had any cmplicatins r negative experiences assciated with previus dental treatment? Yes N If yes, please explain. Generally, hw have yu felt abut yur previus dental appintments? Very anxius /afraid Smewhat anxius/afraid Dn t care ne way r the ther Lk frward t it D yu clench r grind yur teeth in the daytime r at night? Yes N If yes, d yu wear an appliance? If yes, hw lng? Have yu experienced injuries t yur teeth, face r jaw? Yes N If yes, please explain. Have yu experienced any f the fllwing? Scaling and rt planning f teeth Gum surgery Severe pains f face and head Tth extractins Orthdntics/braces Reactin t an injectin Dental implants Jaw surgery Rt canals Head and neck radiatin Prlnged bleeding after dental treatment My Dental Gals Please chse ne. At this time, I am interested in emergency care fr the relief f pain and/r csmetic embarrassment nly becming an established patient t prevent disease/decay and t repair existing prblems csmetic dentistry after I have cmpleted necessary treatment Smile Analysis D yu like the appearance f yur smile? Yes N If nt, please explain what is it abut yur smile that yu wuld like t change? What are yur gals fr yur smile? Are yur teeth all in alignment (straight)? Yes N D yu have spaces that yu dn t like? Yes N D yu like the clr f yur teeth? Yes N D yu like the shape f yur teeth? Yes N Are there ld fillings r dental wrk that yu d nt like the appearance f? Yes N
4 Health Infrmatin Have yu ever had any f the fllwing? Please check thse that apply: Acid reflux Bld disease High bld pressure Strke AIDS/HIV Cancer Jaundice Tuberculsis ADD/ADHD Chemtherapy Jint / valve replacement Tumrs Alchl abuse Cld sres/herpes Kidney disease Ulcers Seasnal allergies Diabetes Type I r II Liver disease Allergy: Cdeine Drug abuse Mental health disrder Pregnant? Allergy: Erythrmycin Dry muth Migraines/headaches If yes, due date Allergy: Latex Eating disrder Nervus disrder Allergy: Penicillin Epilepsy Osteprsis Other (please list) Allergy: Other Fainting Pace maker Glaucma Radiatin treatment Head injuries Respiratry prblems Hemphilia Rheumatic fever Anemia Hepatitis Sickle Cell Disease/Trait Asthma Heart disease Sinus prblems Back pain Heart murmur Sleep apnea Bleeding/cltting disrder Mitral valve prlapse Stmach prblems Are yu currently taking any medicatin? Yes N (if yes, please list including ver-the-cunter meds) D yu take a bld thinner? Yes N Are yu currently underging chem r radiatin therapy? Yes N Are yu nw under the care f a physician? Yes N If yes, please explain: Name f Physician: Phne: D yu smke r use smkeless tbacc? Yes N D yu use e-cigarettes? Yes N Are yu interested in quitting? Yes N Nt at this time T the best f my knwledge, all f the preceding answers and infrmatin prvided are true and crrect. If I ever have any change in my health, I will infrm the dentist/staff at the next appintment withut fail. printed name Signature f patient date
5 ACKNOWLEDGEMENT f RECEIPT f NOTICE f PRIVACY PRACTICES I,, have (printed name) received a cpy f this ffice s Ntice f Privacy Practices r read the Ntice but declined a cpy signature date Fr Office Use Only We attempted t btain written acknwledgement f receipt f ur Ntice f Privacy Practices, but acknwledgement culd nt be btained because Individual refused t sign Cmmunicatin barriers prhibited btaining acknwledgement An emergency situatin prevented us frm btaining acknwledgement Other (specify) Created 9/20/2013
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Medical Histry Althugh dental persnnel primarily treat the area in and arund yur muth, yur muth is a part f yur entire bdy. Health prblems that yu may have, r medicatin that yu may be taking, culd have
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Lee H. Baker, DDS 1243 Augusta West Pkwy Augusta, GA 30909 (706) 855-8989-Phone (706) 855-0321-Fax www.drleebaker.com Welcome to our practice! In order to know you and your child better, please complete
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