General Dental Treatment Consent Form
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- Francis Harrington
- 6 years ago
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1 General Dental Treatment Consent Form I authorize dental treatment including necessary or advisable examination, radiographs (x-rays), diagnostic aids or local anesthesia. In general terms, dental treatment may include but is not limited to one or a number of the following: Administration of local anesthesia Cleaning or the teeth and application of topical fluoride Scaling and root planing with local anesthesia Application of sealants to the grooves of the teeth Treatment of diseased or injured teeth with dental restorations The replacement of missing teeth with a dental prosthesis (crown, partials, etc.) Treatment of diseased or injured oral tissues (hard and/or soft) Treatment of malposed (crooked) teeth and/or developmental abnormalities. Treatment of the canal or pulp chamber that lies in the middle of the tooth and its root also known as endodontic therapy or root canal Risk of Dental Procedures in General Included (but not limited to) are complications resulting from the use of dental instruments, drugs, medicines, analgesics (pain killers), anesthetics and injections. These complications include pain, infection, swelling, bleeding, sensitivity, numbness and tingling sensations in the lip, tongue, chin, gums, cheeks and teeth. Thrombophlebitis (inflammation to a vein), reaction to injections, change in occlusion (biting), muscle cramps and spasms. Tempromandibular jaw (TMJ) joint difficulty, loosening of teeth or restoration in teeth, injury to other tissues. Referred pain to the ear, neck and head, nausea, allergic reactions, itching, bruises, delayed healing, sinus complications and further surgery. Medication and drugs may cause drowsiness and lack of awareness and coordination (which can be influenced by the use of alcohol or other drugs), thus it is advisable not to operate any vehicle or hazardous device, or work for twenty-four hours or until recovered from their effects. Changes in Treatment Plan I understand that during treatment, it may be necessary to change and/or add procedures because of conditions found while working on the teeth that were not discovered during examination. Upon my consent, I will give me permission to the dentist to make any/all changes and additions as necessary. Fillings I understand that I may experience hot and cold sensitivity, pain or discomfort following routine restorative procedures and that this is usually temporary and should settle without further treatment. If in the event that my condition does not get any better, I understand that I may need further dental treatment, the most common being root canal therapy, resulting in additional costs. Crowns (Caps), Bridges and Onlays I understand that sometimes it is not possible to match the color of artificial teeth with natural teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realized the final opportunity to make changes in my new crown or bridge (including shape, fit, size and color) will be before cementation. Once cemented, I understand that any changes in shape, fit, size or color will incur an additional charge. Alternative Treatment I understand that I have the right to choose, on the basis of adequate information, from alternate treatment plans that meet professional standards of care. By signing below, I consent to the general treatments and/or proposed treatment. Patient/Guardian Signature: Patient Name (Printed): Date:
2 Artisan Dentistry Date Name DOB SS Home Address Phone: Cell Home Work Guardians Name/# s Insurance: Ins co: Phone Employer Subscriber - DOB SS/ID Group no. Payer ID Address 2 nd Ins What brought you to our office today?
3 Are you teeth sensitive to: Do you have any general health problems Heat Cold Sweets Have you had any surgeries Biting Pressure Do your gums bleed when brushing Are you currently under a physician s care? Do you have swelling around your gums Reason Do you have any odor or unpleasant taste Are you taking any medications Jaw they What are Do you have or have you noticed Clicking of the jaw To the best of you knowledge, are you or have you had: Pain (joints, ear, side of face) Heart Ailments Difficulty opening or closing Diabetes Difficulty chewing Rheumatic Fever Ringing in the ears Epilepsy Tingling in your finger tips High Blood Pressure Shoulder or neck pain Respiratory Disease Headaches Hepatitis
4 Do you avoid areas in your mouth when brushing HIV Positive Do you feel like you will eventually need dentures Healing Complications Do you smoke Allergy to any Drugs Seizures Are you pregnant? Do you have any dental fears Last dental appt.? Latex allergy Ever need to pre- med w/ anti- bio before dental appts? Have your had any extractions Reason Joint replacement Sleep apnea: Snore when sleeping? Pharmacy: PCP: Emergency Contact:
5 About HIPAA Privacy The Privacy Rule provides federal protections for personal health information held by covered entities and gives patients an array of rights with respect to that information. At the same time, the Privacy Rule is balanced so that it permits the disclosure of personal health information needed for patient care and other important purposes. Your Health Information is Protected by Federal Law Most of us believe that our medical and other health information is private and should be protected, and we want to know who has this information. The Privacy Rule, a Federal law, gives you rights over your health information and sets rules and limits on who can look at and receive your health information. What Information is Protected? Information your doctors, nurses, and other health care providers put in your medical record Conversations your doctor has about your care or treatment with nurses and others Information about you in your health insurer s computer system Billing information about you at your clinic Most other health information about you held by those who must follow this law How is This Information Protected? Covered entities must put in place safeguards to protect your health information. Covered entities must reasonably limit uses and disclosures to the minimum necessary to accomplish their intended purpose. Covered entities must have contracts in place with their contractors and others ensuring that they use and disclose your health information properly and safeguard it appropriately. Covered entities must have procedures in place to limit who can view and access your health information as well as implement training programs for employees about how to protect your health information. What Rights Does This Law Give Me Over My Health Information? Health Insurers and Providers who are covered entities must comply with your right to: Ask to see and get a copy of your health records Have corrections added to your health information Receive a notice that tells you how your health information may be used and shared Decide if you want to give your permission before your health information can be used or shared for certain purposes, such as for marketing Get a report on when and why your health information was shared for certain purposes If you believe your rights are being denied or your health information isn t being protected, you can: o File a complaint with your provider or health insurer o File a complaint with the U.S. Government You should get to know these important rights, which help you protect your health information. You can ask your provider or health insurer questions about your rights. Who Can Look at and Receive Your Health Information The law sets rules and limits on who can look at and receive your health information. To make sure that your health information is protected in a way that does not interfere with your health care, your information can be used and shared: For your treatment and care coordination To pay doctors and hospitals for your health care and to help run their businesses With your family, relatives, friends, or others you identify who are involved with your health care or your health care bills, unless you object To make sure doctors give good care and nursing homes are clean and safe To protect the public's health, such as by reporting when the flu is in your area To make required reports to the police, such as reporting gunshot wounds
6 Your health information cannot be used or shared without your written permission unless this law allows it. For example, without your authorization, your provider generally cannot: Give your information to your employer Use or share your information for marketing or advertising purposes Share private notes about your health care
7 Personal Health Information Release Form (HIPAA Release Form) Name: Date of Birth: / / Release of Information [ ] I authorize the release of any and all information including diagnosis, financial, dental records, examinations rendered to me and claims information. This information may be released to: [ ] Spouse [ ] Child(ren) [ ] Other [ ] Information is not to be released to anyone. This Release of Information will remain in effect until terminated by myself in writing. Messages Please call [ ] home [ ] work [ ] cell phone number: If unable to reach me: [ ] please leave a detailed message
8 [ ] please leave a message asking me to return your call [ ] The best time to reach me is (day) between (time) I understand that this office will try and accommodate my wishes about my contact information, but may have to contact me at the other numbers if unable to contact me at my requested number/location. Patient Signature: Date: / /
Informed Consent. (Initials )
Informed Consent 1. EXAMINATIONS AND X-RAYS I understand that the initial visit may require radiographs in order to complete the examination, diagnosis and treatment plan. I understand I am to have work
RESPONSIBLE PARTY INFORMATION:
Practice Limited To Endodontics 113A Tavern Road, Martinsburg, WV 25401 (304) 263-9191 Fax: (304) 263-9659 PATIENT HISTORY: M.I. Patient s Home Phone: ( ) Work Phone: ( ) Cell Phone: ( ) Gender: Male or
MEDICAL AND PERSONAL HISTORY
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PATIENT REGISTRATION
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New Patient Information
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PATIENT HEALTH HISTORY
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Kingsland Family Dental Registration and Medical History
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ADULT PATIENT REGISTRATION FORM Name Social Security # Gender Preference M F Transgender (M to F) Transgender (F to M)
ADULT PATIENT REGISTRATION FORM Name Social Security # Gender Preference M F Transgender (M to F) Transgender (F to M) Date of Birth (MM/DD/YY) Primary Address City State ZIP PATIENT INFORMATION Alternate
Tell Us About Your Child. Who is Accompanying Your Child Today? Parent Information. Primary Dental Insurance
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Welcome to Our Office!
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Patient Registration. First Name: Last Name: Middle Initial: Address: City, State, Zip: First Name: Last Name: Middle Initial:
Patient Registration First Name: Last Name: Middle Initial: Preferred Name: DOB: Sex: Male Female Address: City, State, Zip: Home#: Cell#: Soc. Sec. #: Referred By: Previous Dentist: Responsible Party
WELCOME Patient Registration Date:
Patient Information WELCOME Patient Registration Date: Mr. Mrs. Ms. Dr. Name: Last First MI Address: Street Apt. # City State Zip Code Home Tel #: Work #: Cell #: Sex: Female Male Birth Date: Married Single
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Last: First: MI: Nickname:
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Patient Information. Spouse or Responsible Party Information. Insurance Information
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PATIENT INFORMATION SHEET PERSON RESPONSIBLE FOR PAYMENT OF THIS ACCOUNT
PATIENT INFORMATION SHEET Referred By: Patient s Name: SSN: Date of Birth: Address: City/Zip: Phone #: Sex: M / F Marital Status: M / S / W / D No. of Dependents: Email Address: Emergency Contact Person:
Get Acquainted Questionnaire Tell Us About Your Child!
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MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY. Patients s Name Date Yes No Yes No
MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY Patients s Name Date Yes No Yes No Anemia Arthritis Artificial Joints or Heart Valve Asthma Cancer/tumors Chest
Patient Registration
Patient Registration First name: Last name: Patient is: Responsible party Child Address: City: State: Zip: Home phone Cell phone: Work phone: Sex: Male Female Birth date: Material status: Single Married
Name: Last First Middle. Address: Street or P.O. Box # City State Zip code Phone Number: Home: Work: Pager#: Cell Phone: Address:
Lake Pointe Dental Group Dr. Shannon Maddox and Team www.lpfdokc.com 10914 Hefner Pointe Drive, #150 (405)946-5558 Oklahoma City, OK PLEASE COMPLETE AND RETURN TO BUSINESS OFFICE Name: Last First Middle
Patient Name Last First MI Preferred Name SS# Date of Birth / / Drivers License # Home Address City Zip
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PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)
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Access Endodontics Marat Tselnik, DDS -PRACTICE LIMITED TO ENDODONTICS-
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Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:
Thank you for the opportunity to evaluate your dental condition. In order to provide the best service for you, please complete the following information. About You Last Name: First Name: Address: City:
(Please complete the enclosed forms prior to your visit and bring them in with you.)
Hello! We would like to extend to you a very warm welcome to our dental practice. We are committed to doing everything possible to provide you with high quality dental care and also make your visit to
Who is responsible for this account Relationship to patient. How did you hear about us (referral, facebook, etc.)?
EMERGENCY CONTACT INSURANCE PATIENT INFORMATION Name of Minor/Child SSN Sex: M F Age Birthdate Nickname Mailing Address City, State, Zip Physical Address City, State, Zip Home Phone Work Cell Email Address
PATIENT S NAME GENDER First Middle Init. Last Male/Female. Home Address. PATIENT EMPLOYER Bus. Phone. Employer Address. NAME OF SPOUSE Birth Date
PATIENT INFORMATION RECORD The following information is needed for our records. Please print answers to all questions. PATIENT S NAME GENDER First Middle Init. Last Male/Female Birth Age Marital Status
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
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GENERAL QUESTIONS CONTACT INFORMATION
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Patient Registration
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MEDICAL HISTORY. PATIENT NAME Birth Date
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Employment Information Patient Employed By: Occupation: Phone: Work Mailing Address:
Patient Information Patient Name: Today s : Dr. Mr. Mrs. Ms. Prefered Name: Maritial Status: Married Single Divorced Separated Widowed Sex: Male Female Address: Social Security #: of Birth: Home Phone:
MEDICAL AND PERSONAL HISTORY
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We Would Like to Get to Know You Better!
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Patient Registration Patient s Full Name: Home Address: Home Phone Number: Cell Phone Number: Social Security #: DOB: Relationship Status: Married Divorced Single Place of Employment: Work Address: Work
Welcome to South 40 Dental! Tell Us About Yourself
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Welcome to Our Office! Patient Registration Paul S. Jackson, D.M.D. 1345 E. Fort Union Blvd. Salt Lake City, Utah, 84121 Patient s Name Birth Date Age Gender Home Address City State Zip Home Phone Cell
RICHARD J. SORBERA, D.D.S. SHIBLY D. MALOUF, D.D.S., INC. DIPLOMATES AMERICAN BOARD OF ORAL AND MAXILLOFACIAL SURGERY
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PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:
Date: PATIENT INFORMATION Name: Birth date: First Last Address: Street City State Zip Home phone: Work phone: Cell phone: E-mail address: How would you prefer to be contacted? Home Cell Text E-mail Are
New Patient Information
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Insurance Information Release Form
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SOFT TISSUE GRAFTING INFORMATION AND CONSENT
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Dental Patient Survey
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ABOUT YOUR CHILD PARENT INFORMATION Child's Name: Mother's Name: Last Name First M.I. Employer: Nickname: Male Female Work Phone: of Birth: Age: SSN: Home Address: Father's Name: Employer: City State Zip
REGISTRATION FORM PATIENT INFORMATION. Patient s last name: First: Middle: Marital status: Occupation: Employer: Employer phone #: Physician name:
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PATIENT INFORMATION OFFICE PAYMENT POLICY PLEASE READ AND SIGN
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Endodontic Associates of Alaska 800 E. Dimond Blvd. Ste Anchorage, AK 99515
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GIVE KIDS A SMILE. Sincerely,
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STEPHEN C. SNITZER, D.D.S.,
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Registration. Secondary Dental Insurance Subscriber s Name Date of Birth Social Security # Relationship to Patient Subscriber s Employer
Patient Name of Birth Sex Age How do you wish to be addressed Single Married Separated Divorced Widowed Minor Home Address City State Zip Home Phone # Cell phone # Email Fax # Driver s License # Work Address
Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address:
Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address: Whom may we thank for referring you to us? Names of
MEDICAL HISTORY FULL NAME D.O.B. SEX
MEDICAL HISTORY FULL NAME D.O.B. SEX MEDICAL PHYSICIAN OF LAST MEDICAL VISIT HOW IS YOUR GENERAL HEALTH? HEIGHT WEIGHT PLEASE CHECK THE BOX TO THE LEFT IF YOU HAVE HAD ANY OF THE FOLLOWING: AIDS/HIV EPILEPSY
Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:
Thank you for the opportunity to evaluate your dental condition. In order to provide the best service for you, please complete the following information. About You Last Name: First Name:_ Address: City:_
NEW PATIENT PAPERWORK
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Married Single Widowed Legally Separated. Full Time Part-time Retired Not Employed Currently
First Name Last Name MI Preferred Name Gender Birthday SSN M F Same address for entire family Address Address (cont) City State Zip Home Phone Mobile Email Martial status Married Single Widowed Legally
Chapel Hill Pediatric Dentistry
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Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes. Yes No Yes No
Medical History Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking,
General Dentistry Cosmetic Dentistry Endodontics Oral Surgery Orthodontics Periodontics DENTAL HISTORY. How may we help you today?
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PATIENT MEDICAL HISTORY
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Essex Podiatry Associates Jeffrey N. Kaplan, DPM Neil E. Goldberg, DPM
General Vital Information Date: Name: Nickname: Sex: M / F SS #: DOB: E-mail: Home #: Address: Work #: City: State: Zip: Cell #: Primary Care Physician: PCP Phone: PCP Address: Last Visit: Emergency Contact
NEW Adult Patient Information
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MOBILE PREMIER PEDIATRIC DENTISTRY Maureen T. Baldy, D.M.D.
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PATIENT INFORMATION SCHOOL/LOCATION
PATIENT INFORMATION WWW.FAMILYCAREDENTISTRY.NET Date: NEW PATIENT UPDATE Patient: LAST FIRST MI PREFERRED TITLE MALE FEMALE CHILD* STUDENT** SINGLE MARRIED DIVORCED WIDOWED *IF CHILD, PROVIDE PARENT/GUARDIAN
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