Directions to the Barnes Road Professional Campus

Transcription

1 11786 SW BARNES RD, STE 360 PORTLAND, OR (503) Directions to the Barnes Road Professional Campus Our office is located in the Barnes Road Professional Campus in southwest Portland on S.W. Barnes Road two blocks west of S.W. Cedar Hills Blvd. Please call our office for directions if you are unfamiliar with the area. Coming from Portland on Sunset Highway (26): Take Exit 68 (Cedar Hills Blvd) and turn right onto SW Cedar Hills Blvd. At the first light, turn left onto SW Barnes Rd. Go approximately 0.3 miles and just past SW 117th/Sunset Medical Clinic. Get into the left turn lane and turn into the Barnes Road Professional Campus. Our building (11786) is near the back of the campus behind the parking structure. Coming from the South on Highway (217): At the rth end of Hwy 217, take the Barnes Road exit and then stay in the left lane to head West on Barnes Road. Travel on Barnes Road approximately 0.3 miles past Cedar Hills Blvd and just past SW 117th/Sunset Medical Clinic. Get into the left turn lane and turn into the Barnes Road Professional Campus. Our building (11786) is near the back of the campus behind the parking structure. Coming from the West on Sunset Highway (26): Take Exit 68 (Cedar Hills Blvd). At the bottom of the ramp turn left on SW Cedar Hills Blvd. At the second light, turn left onto SW Barnes Road. Go approximately 0.3 miles and just past SW 117th/Sunset Medical Clinic. Get into the left turn lane and turn into the Barnes Road Professional Campus. Our building (11786) is near the back of the campus behind the parking structure.

2 REGISTRATION FORM Thank you for expressing your confidence in choosing our practice! We look forward to assisting you with your dental needs. Please fill out this form in ink only. If you have any questions regarding this form do not hesitate to ask for assistance. We will be happy to help. Patient Name: Birth Date: Last M.I. First SS#: DL#: Sex: Male Female Marital Status: Single Married Divorced Widowed Partnered Spouse/Guardian Name: Home Address: City/State/Zip: Home Phone: Cell: Work: Address: What is the best way to contact you? Home Cell Work Employer Name: Occupation: Spouse/Guardian Name: Who may we thank for referring you? RESPONSIBLE PARTY Name of person responsible for account: DOB: Age: SS#: Phone: Address: City/State/Zip: Employer Name: Work Phone: *Please list an Emergency Contact not living with you. Name: Phone: Relationship: Relationship: PRIMARY DENTAL INSURANCE INFORMATION Subscriber s Name: Relationship: DOB: SS#: ID#: Insurance Company: Group #: Ins Phone#: Ins Address: Employer s Name: Work Phone: Do you have Secondary Dental Insurance? YES NO Subscriber s Name: Relationship: DOB: SS#: ID#: Insurance Company: Group #: Ins Phone#: Ins Address: Employer s Name: Work Phone: I hereby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the dental office to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payers and/or other health care professionals as is beneficial for payment or dental care. Signature of Parent/Guardian Date

3 MEDICAL HISTORY Patient Name: DOB: Check ( ) if you have or have had problems with any of the following: AIDS/HIV Positive Fainting or dizziness Radiation Treatment Anemia Fibromyalgia Respiratory Disease Angina Glaucoma Rheumatic Fever Anxiety Headaches Scarlet Fever Arthritis, Rheumatism Heart Attack Shortness of Breath Artifical Heart Valves Heart Murmur Seizures Artifical Joints, Date Heart Disease Sinus Trouble Asthma or Hay Fever Hemophilia Stroke Hepatitis Type Swollen Feet or Ankles Bleeding abnormally, with Herpes Swollen Neck Glands Blood Disease extractions or surgery High Blood Pressure Thyroid Problems Blood Transfusion Jaundice Tonsillitis Cancer Therapy Jaw Pain Tuberculosis Chemical Dependency Kidney Disease Ulcer Chemotherapy Leukemia Venereal Disease Circulatory Problems Liver Disease Weight Loss, unexplained Congenital Heart Lesions Low Blood Pressure Have you had any serious COPD Measles or mumps illness or surgeries? Cortisone Treatments Mitral Valve Prolapse Diabetes, Type Neurological Problems Emphysema Osteoporosis Endocarditis Pacemaker Epilepsy Psychiatric Care If, describe: Medications routinely used in dental treatment may interact with both prescription and illegal street drugs. Check ( ) the medications you are presently taking or medications you have taken in the past. Presently Taken in Taking the past Presently Taken in Taking the past Cortisone or Other Steroids Coumadin, Heparin, Warfarin or other blood thinners Dilantin Diuretics (water pills) Fen-phen (Lonimin, Adipex, Fastin, Phentermine, Pondimin, Fenfluramine, Redux, Dexfenfluramine) Heart Medications such as Digoxin, Nitroglycerin or Digitalis Ibuprofen (Motrin) Anesthetics, General Antacids Anti-anxiety Medications Anti-depressants Antihistamines Daily Aspirin Regimen Birth Control Pills Blood Pressure Medications Codeine, Demerol Presently Taken in Taking the past Insulin or Diabetes Medications Sedatives or Tranquilizers Sleeping Pills (Barbiturates) Thyroid Medication such as Synthroid, Levoxyl or Levothyroxine Tylenol (Acetominophen) Biosphosphonates Check ( ) your current use of: Tobacco Packs per day Women: Are you pregnant? Nursing? List the other medications you are currently taking and what condition you are taking them for. Include vitamins, supplements, herbs and over the counter medications. Medication Condition Prescribing Doctor Pharmacy Name Allergies: Acrylic Aspirin Local Anesthetics Other Clindamycin Codeine Latex Metal Penicillin Sulfa Drugs Pharmacy Phone If yes, please explain: Do you have any other health needs you should bring to our attention? To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. Signature of Patient, Parent, Guardian or Personal Representative Date Please print name of Patient, Parent, Guardian or Personal Represtative Relationship to Patient

4 DENTAL HISTORY Patient Name: Previous Dentist: DOB: Phone: Date of Last Appt: Why did you leave your previous dentist? Date of Last X-Rays: Check () if you have or have had problems with any of the following: Bad Breath Chew on one side of mouth Bleeding gums Tobacco use Gums swollen or tender Chewing on foreign objects Sores, blisters, growths on lips or mouth Fingernail biting Burning sensation on tongue Thumb sucking Biting cheeks or lips Tongue thrusting Dry mouth Pain on brushing teeth Mouth breathing Loose or broken teeth Chewing Loose or broken fillings Swallowing Food collection between the teeth Talking Sensitivity to cold Prominent gag reflex Sensitivity to hot Snoring Sensitivity to sweets Periodontal treatment Sensitivity when biting Pyorrhea or trench mouth Stained teeh Orthodontic Treatment Grinding or clenching teeth Wisdom teeth extracted Clicking or popping jaw Bite problems Jaw pain or fatigue Missing teeth Opening or closing jaw Shifting position of teeth Pain around ear How often do you brush? How often do you floss? How often do you have your teeth cleaned? How often do you change toothbrushes? PATEINT GOALS What is your goal for dental treatment today? Are you in discomfort today? Are you pleased with the appearance of your teeth? If no, please explain: Do you like your smile? If no, please explain: Does dental treatment make you nervous? If yes, please explain: Have you been pleased with your previous dental care? Have you ever had a bad experience in a dental office? If so, please explain: How can we help improve your teeth and smile? Signature of Patient Date

5 Cedar Creek Dental Cristina L. Rust, D.M.D SW Barnes Rd Ste 360 PORTLAND OR, (503) At Cedar Creek Dental we are determined to show each and every patient an outstanding experience. It s always been our belief that your time is valuable, therefore we have one theory about scheduling, you deserve our undivided attention. For this reason, we do not double-book like other practices and accept unscheduled appointments in the event of an emergency ONLY. When we schedule a dental visit, that time is yours. It belongs to you. So when cancellations happen, sometimes as little as an hour ahead of time, we feel like we have been stood up for a very important appointment, an appointment that has everything to do with your on-going dental health. Of course flat tires, sick children, and family emergencies do happen and we understand, but the cost of needlessly missed appointments is borne by us all. Our staff has made a promise, professionally and personally, to give you the concern, respect and care that makes our office a comfortable and pleasant place to visit. We ask our patients to give us at least 48 hours notice if they cannot keep an appointment. We try very hard to keep our schedule and hope our patients try too. If the 48 hour notice is not upheld and there is either a no-show to the scheduled appointment or less than 48 hours notice, we may charge your account $50.00 or request a deposit of 50% to be paid in advance to reserve your next appointment. Our feeling is this, your dental health is important and it deserves respect ~ yours and ours. I have read and acknowledge the above statement. Date: Signature: If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form: Relationship to patient: Print Name: Source of Authority:

6 Cedar Creek Dental Cristina L. Rust, D.M.D SW Barnes Rd Ste 360 PORTLAND OR, (503) Financial Agreement Thank you for choosing Cedar Creek Dental for your dental needs. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care easy and manageable for our patients by offering several payment options. Available Options: - Cash, Check, Visa, MasterCard, or Discover Card - In office payments extended over 3-months via automatic credit card withdrawal - Outside financing Please note: Cedar Creek Dental requires payment at time of service. For patients with dental insurance we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment, however your ESTIMATED portion is due at the time of the appointment. Please note we can only ESTIMATE what your insurance will remit as your insurance is a contract benefit between you, your employer, and the insurance company. We are happy to assist you in billing your insurance and will do our best to maximize your benefits; however, you are ultimately responsible for the cost of treatment performed. Please indicate method of payment you prefer: ( ) Payment in full ( ) Automatic credit card withdrawal ( ) Financing plan upon approval We charge 18% interest on all past due accounts, $50.00 for appointments missed or cancelled without a minimum of 48 hour notice, and $35.00 for any returned check. If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need. Patient, Parent or Guardian Signature Date Patient Name (Please Print)

7 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 the consent. Signature: I,, have had full opportunity to read and consider the contents of this consent form and your tice of Privacy Practices. I understand that by signing this consent form I am giving my consent to use and disclose my protected health information to carry out treatment, payment activities and health care operations. Signature: Date: If this consent is signed by a personal representative on behalf of the patient, complete the following: Personal representative name: Relationship to Patient: YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT. Revocation of consent: I revoke my consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations. I understand that revocation of my consent will not affect any action you took in reliance on my consent before you received this written notice of revocation. I also understand that you may decline to treat or continue to treat me after I have revoked my consent. Signature: Date:

8 Cedar Creek Dental Cristina L. Rust, D.M.D SW Barnes Rd Ste 360 PORTLAND OR, (503) CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION Section A: Patient Giving Consent Name: Address: Telephone: Social Security #: DOB: Section B: 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. tice of Privacy Practices: You have the right to read our tice 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 accompanies this consent. 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 tice of Privacy Practices. If we change our privacy practices, we will issue a revised tice 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 tice of Privacy Practices, including any revisions of our notice, at any time by contacting: Contact person: Kassy McBee Address: SW Barnes Rd., Ste. 360 Portland, Oregon Telephone: (503) Fax: (503) E:mail: Office@cedarcreekdentistry.com