GRAND DENTAL STUDIO GENERAL COSMETIC IMPLANT SEDATION
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1 GRAND DENTAL STUDIO GENERAL COSMETIC IMPLANT SEDATION 1057 NW Grand Blvd., Oklahoma City, OK dentistokc.com P: F: Welcome to Grand Dental Studio. We are so honored you have chosen our dental team to take care of you! Our mission at Grand Dental Studio is to provide general, sedation, implant, and cosmetic dental care in a way that we hope changes your perception of dentistry. At Grand Dental Studio, we believe that it s our focus on the details that set us apart from other dental care providers. Every day we strive to put our patients first by starting and ending our appointments on time and treating everyone like family. We partner with you to provide superior general, cosmetic, implant, and sedation dentistry services for the entire family. We believe in total wellness so please talk to us about your health including but not limited to teeth and gum concerns, headaches, fatigue, snoring, and any dental hygiene questions you may have for you or your family. We want to encourage more people to take care of their dental health. Recent statistics indicate that a little over half of the people in Oklahoma go to a dentist regularly. That is why we are offer a FREE First Visit. This includes exam with the doctor and x-rays. Please tell your friends about this program. We invite you to ask questions because we want to create a lifelong relationship with you. We seek daily to be Oklahoma s Best Dental Experience TM. Thank you for being here today! - 1 -
2 PATIENT REGISTRATION Today s Date Patient s Name Sex: M F Birthdate Age Home Address City State Zip Please Circle One: Single Married Separated Widow Your Soc. Sec. # Home Cell Ph. # Ph. # Address Your Work How Long Employer Ph. # Employed Are you a full time student? If so, where? Mother s Father s If patient is minor, we need: DOB DOB Person responsible for account DOB SSN # Relationship Name of spouse Spouse s (parent s) (parent if minor) Soc. Sec. # Address City State Zip Spouse s (parent s) Work Cell Employer Ph. # Ph. # EMERGENCY INFORMATION Name, address & telephone of a relative not living with you. Dental concerns you wish to discuss today? How did you hear about our office? Sign Facebook Website Mail Advertisement Referral If referral, please let us know who we can thank. Insured s Name DENTAL INSURANCE INFORMATION (Primary Carrier) Relationship to Patient Insured s Employer Insurance Co. Insurance Co. Address Phone # DOB SS#/Member ID # Group # - 2 -
3 MEDICAL HISTORY Patient Name Nickname Age Name of Physician / and their specialty Most recent physical examination Purpose What is your estimate of your general health? Excellent Good Fair Poor DO YOU HAVE or HAVE YOU EVER HAD: YES NO 1. hospitalization of illness or injury 2. an allergic reaction to aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline sulfa local anesthetic fluoride metals (nickel, gold, silver, ) latex other 3. heart problems, or cardiac stent within the last six months 4. history of infective endocarditis 5. artificial heart valve, repaired heart defect (PFO) 6. pacemaker or implantable defibrillator 7. artificial prosthesis (heart valve or joints) 8. rheumatic or scarlet fever 9. high or low blood pressure 10. a stroke (taking blood thinners) 11. anemia or other blood disorder 12. prolonged bleeding due to a slight cut (INR>3.5) 13. emphysema, shortness of breath, sarcoidosis 14. tuberculosis, measles, chicken pox 15. asthma 16. breathing or sleep disorders (i.e. sleep apnea, snoring, sinus) 17. kidney disease 18. liver disease 19. jaundice 20. thyroid, parathyroid disease, or calcium deficiency 21. hormone deficiency 22. high cholesterol or taking statin drugs 23. diabetes (HbA1c= ) 24. stomach or duodenal cancer 25. digestive disorders (i.e. celiac disease, gastric reflux) 26. osteoporosis/osteopenia (i.e. taking bisphosphonates) 27. arthritis, rheumatoid arthritis, lupus 28. glaucoma 29. contact lenses 30. head or neck injuries 31. epilepsy, convulsions, (seizures) 32. neurologic disorders (ADD, ADHD, prion disease) 33. viral infections and cold sores 34. any lumps or swelling in the mouth 35. hives, skin rash, hay fever 36. STI/STD 37. hepatitis (type ) 38. HIV / AIDS 39. tumor, abnormal growth 40. radiation therapy 41. chemotherapy, immunosuppressive 42. emotional problems 43. psychiatric treatment 44. antidepressant medication 45. alcohol / street drug use ARE YOU: 46. presently being treated for any other illness 47. aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, or diarrhea) 48. taking medication for weight management (i.e. fen-phen) 49. taking dietary supplements 50. often exhausted or fatigued 51. experiencing frequent headaches 52. a smoker, smoked previously or use smokeless tobacco 53. often unhappy or depressed 54. FEMALE - taking birth control pills 55. FEMALE - pregnant 56. MALE - prostate disorders YES NO Describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. (i.e. Botox, Collagen Injections) List all medications, supplements, and or vitamins taken within the last two years DRUG PURPOSE DRUG PURPOSE Ask for an additional sheet if you are taking more than 6 medications. PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING. Patient s Signature Date Doctor s Signature Date - 3 -
4 GRAND DENTAL STUDIO GENERAL COSMETIC IMPLANT SEDATION STOP-BANG Questionnaire for Obstructive Sleep Apnea (OSA) 1. Do you Snore loudly (louder than talking or loud enough to be heard through closed doors)? 2. Do you often feel Tired, fatigued, or sleepy during daytime? 3. Has anyone Observed you stop breathing during your sleep? 4. Do you have or are you being treated for high blood Pressure? 5. Body Mass Index (BMI) more than 35 (use the formula to calculate your BMI)? BMI Formula: (your weight in pounds X 703) BMI= (your height in inches X your height in inches) 6. Age over 50 yr old? 7. Neck circumference greater than 40 cm? 8. Gender male? Scoring: Answering yes to three or more of the 8 questions indicates that you are at High Risk for OSA. Answering yes to less than three questions indicates that you are at Low Risk for OSA. If you scored in the High Risk for OSA category, a sleep study or an evaluation by a sleep specialist may be warranted
5 GRAND DENTAL STUDIO GENERAL COSMETIC IMPLANT SEDATION How do you like your smile? Are you happy with the appearance of your smile? * * Are your teeth straight? * * Do you like the color of your teeth? * * Do you like the shape of your teeth? * * Do you have old fillings that you don t like? * * What would you like to change most about the appearance of your teeth? Do you have any concerns that you would like to share?
6 Acknowledgment of Receipt of tice of Privacy Practices and HIPAA n-secure Communication Consent Form This consent form allows Grand Dental Studio to use and disclose information about me protected under the Health Insurance Portability and Accountability Act of This information may be used or disclosed to carry out treatment, payment or health care operations. Grand Dental Studio has provided me with a tice of Privacy Practices, which more completely describes such uses and disclosures. It provided this notice prior to my signing this form in accordance with my right to review its practices before signing consent. I understand that the terms of the tice of Privacy Practices may change and that I may obtain revised notices by contacting the Privacy Officer at Grand Dental Studio. I understand that at any time I have the right to revoke this consent provided that I do so in writing, but that Grand Dental Studio may still use information to complete any actions that it began prior to my revoking consent and which rely on my protected health information. I understand that Grand Dental Studio may refuse service if I revoke this consent. I understand that I have the right to request now and in the future how protected health information is used or disclosed to carry out treatment, payment and health care operations, and must be provided by me in writing. I understand that while Grand Dental Studio is not required to agree to my requested restrictions, if it does agree, it is bound by that agreement. By my signature below, I affirm the above information. Signature of Patient Signature of Parent (if minor)/ Authorized Representative Date: Date: I hereby authorize Grand Dental Studio to use unsecured and mobile phone text messaging to transmit to me the following protected health information: 1) Information related to the scheduling of appointments; and, 2) Information related to billing and payment. I hereby authorize that Grand Dental Studio may leave messages on my voic to confirm appointments, and/or speak with other members of my household and leave messages with them regarding my appointments. Home Phone Office Phone Cell Phone I hereby authorize that Grand Dental Studio may disclose my health information to any person(s) who accompany me to my appointment, and are present with me in the office while I meet with my dentist and staff. I hereby authorize that Grand Dental Studio may disclose my personal health information to the person who I have listed as my emergency contact. I hereby authorize that Grand Dental Studio may disclose my personal health information to the following person(s). Name Telephone Number Relationship to Patient - 6 -
7 CLIENT PHOTO RELEASE FORM I,, hereby authorize Grand Dental Studio to take photographs, x-rays, intra oral pictures, slides and /or videos of my facial area, jaws, teeth or anything in reference to my dental treatment. I understand that these diagnostic tools will be used as a record of my care and may be used for educational purposes in lectures, demonstrations and advertising. Their use may include, but are not limited to, website publication, newspapers, magazines, phone books, television and professional (dental magazines and journals), videos and social media. I also understand that if the photographs, x-rays, intra oral pictures, slides and/or videos of my facial area, jaws, teeth or anything in reference to my dental treatment are used in any type of marketing publication or as part of any presentation or demonstration, that my name or other identifying information may be used unless otherwise stated below. I do not expect compensation, financial or otherwise, for the use of photographs. I understand that information disclosed pursuant to this authorization may be subject to redisclosure and may no longer be protected by HIPAA privacy regulations. PLEASE INITIAL: I do not mind if my name and face are used in any of the above mentioned situations. EXCEPTIONS: I do not wish to have my name shown or released. I do not wish to have my face shown. Signature: Date: If patient is a minor: Parent/Legal Guardian: Date: Signature: Date: - 7 -
MEDICAL HISTORY. List all medications, supplements, and or vitamins taken within the last two years. Drug Purpose Drug Purpose
DO YOU HAVE or HAVE YOU EVER HAD: 1. hospitalization for illness or injury 2. an allergic or bad reaction to any of the following: aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline
PERSONAL INFORMATION First: Last: Middle:
Today s Date: PERSONAL INFORMATION First: Last: Middle: Email: Home Phone: Business/Cell Phone: Address: City: State: Zip: Social Security: Date of Birth: Sex: M F Emergency Contact: Home Phone: Relationship:
Patient Information. Address: Responsible Party/Insurance Policy Holder. (if someone other than patient) First Name: Last Name MI: Address:
Patient Registration (complete form must be filled to process insurance claim) Patient Information First Name: Last Name: MI: Address: City: State: Zip: Home Phone: Cell Phone: Email Address: Would you
3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication
MEDICAL HISTORY Patient's Name: Birth Date: 1. Has there been any change in your general health within the past year? 2. Are you now under the care of a physician or health care professional? Physician's
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
Last: First: MI: Nickname:
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
New Patient Paperwork
New Patient Paperwork NAME: Last: First: MI: Nickname: ADDRESS: Street: City: State: Zip: DOB: Male Female SSN#: - - Home: ( ) Work: ( ) Mobile: ( ) Email: If applicable, Spouse s Name: Emergency Contact
Authorization to confirm appointment ( Patient Signature )
Patient Info Today s date / / Mobile phone # Patient Name: Mr. Miss Mrs. Ms. Dr. Rev. Sr. Fr. Street Address City State ZIP Home phone # _ Work phone # _ Email of birth / / Soc. Sec. # - - Referred by
PATIENT MEDICAL HISTORY
Patients Name: PATIENT MEDICAL HISTORY Address: Date of Last Visit: Date of Med History City: State: Zip: Email: Home Phone: Work Phone: Birth Date: Social Security No: Marital Status: Primary Dental Guarantor:
1427 West State Hwy J Ozark, MO
1427 West State Hwy J Ozark, MO 65721 417 581-3600 www.exceldental.com Name Last First Middle SS# Preferred Name Date of Birth Male Female Marital Status Address City/State/Zip Email Home Phone Cell Phone
Patient Name: Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV. Yes No Liver Disease.
Patient Name: Date: HEALTH HISTORY Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV Heart Murmur Tuberculosis ANEMIA Heart Problems Tumor or growth on head/neck Arthritis,
Marks Family Dentistry. PATIENT REGISTRATION
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Welcome to South 40 Dental! Tell Us About Yourself
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Julia A. Hallisy, D.D.S., Inc.
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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
Preferred Name: First Name: Last Name: Middle Initial: Home Phone: Work Phone: Ext: Cellular:
ID: PATIENT REGISTRATION DATE First Name: Patient Is: Policy Holder Responsible Party Last Name: Preferred Name: Middle Initial: Responsible Party (if someone other than the patient) First Name: Last Name:
NAME: last first middle Mr. Mrs. Ms. Dr. city state zip Single Married Divorced Widowed Separated
WELCOME! The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out these forms completely. The better we communicate, the
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
A B O U T Y O U D E N T A L I N F O R M A T I O N
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PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)
PATIENT INFORMATION Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell) Email: Gender: Male ( ) Female ( ) Age: Birthdate: Marital Status: Married ( ) Widowed ( ) Single ( )
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
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,
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions.
HEALTH HISTORY Since your well-being is our primary concern, please take the time to accurately answer the questions. Date: Patient Full Name: DOB: Sex: M / F Social Security #: Address: Home #: Cell #:
PATIENT REGISTRATION
PATIENT REGISTRATION Patient Information Whom may we thank for referring you to our office? _ Date Preferred Name (Circle) Patient Name Age Birthdate M or F First M.I. Last Residence & Mailing Address
Name: Last First Middle. Address: Street or P.O. Box # City State Zip code Phone Number: Home: Work: Pager#: Cell Phone: Address:
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Kingsland Family Dental Registration and Medical History
Registration and Medical History Date: Patient Information Patient Name: DOB: / / Age Last First M Social Security# - - Sex: M F Marital Status: Single Married Child Other Spouse or Parent Name: Street
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 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
Patient Information. Spouse or Responsible Party Information. Insurance Information
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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
Creating and maintaining your oral health is our primary goal. Thank you for giving us the opportunity to pursue this goal with you.
Welcome to our wonderful family of patients. Thank you for selecting us as your personal dental care team. We will strive to make your relationship with us a pleasant and rewarding one. A firm foundation
NAME Birthday Social Security # HOW OR WHO REFERRED YOU TO OUR OFFICE? Cell OCCUPATION EMPLOYER SPOUSE S NAME OCCUPATION/EMPLOYER
Personal Information-Health History Dr. Vicki Borowski, D.D.S. 17300 Preston Road, Suite 100, Dallas, TX 75252 Phone: 972-380-6223 Fax: 972-248-6560 Email: info@vickiborowski.com web: www.vickiborowski.com
If yes, please explain: Yes. If yes, please explain: Yes
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Tell Us About Your Child
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MEDICAL HISTORY FULL NAME D.O.B. SEX
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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.)
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PATIENT REGISTRATION INFORMATION DENTAL INSURANCE INFORMATION. Title:! Mr.! Mrs.! Ms.! Miss! Dr. Patient: Last Name: First Name: Middle:
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MEDICAL AND PERSONAL HISTORY
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KODISH DENTAL GROUP. If you could whiten your teeth for a cost anyone could afford, would you do it? Y N
DENTAL History Please check any of the following that apply to you: Sensitvity (Hot, Cold, Sweet) Where? UR LR UL LL Headaches, ear aches, neck or jaw joint pain Mouth Ulcers or cold sores Teeth or fillings
Address, including apt # City State Zip. Do you have an address? We do not share addresses with anyone. Home: ( ) Work: ( ) Cell: ( )
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WELCOME. About You. Dental Insurance. Responsible Party s Information. Emergency Contact. Pharmacy Information
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Date of Birth: Age: Sex: Male Female Marital. Driver's Lic S M D. Status: Address:
Houston Weight Loss and Lipo Centers Patient Name: Address: City, State : Apt: Zip: Email*: *By providing your email address you are agreeing to communication via email. Home Phone Primary contact Work
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:
PATIENT FORMS. Patient Information. Responsible Party. Referral Information. Name: Birth Date: Social Security #: Home Phone: Cell Phone:
PATIENT FORMS Patient Information Name: Birth Date: Social Security #: Home Phone: Cell Phone: Email: Address: City: State: Zip: Responsible Party Name of person responsible for this account: Relationship
GENERAL QUESTIONS CONTACT INFORMATION
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Patient Registration
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: Patient s Name: Social Security #: How do you wish to be addressed? of Birth: Age: Male Female Minor Single Married Separated Divorced Widowed No answer Residence Street Address: _ City: State: Zip code:
PATIENT INFORMATION SHEET PERSON RESPONSIBLE FOR PAYMENT OF THIS ACCOUNT
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Patient Information 433 W. University Dr. Rochester, MI 48307 www.rochesteradvanceddentistry.com +1 248 656-2020 SLEEP SCREENING QUESTIONNAIRE Name: DOB: Age: Address: Employer: SS# Home Phone: Work Phone:
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Patient Registration. Additional Information. Insurance Information. Patient s Full Name: Date: Home Address:
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Date: PATIENT REGISTRATION Patient Name: Prefers to be called: Address: City: State: Zip: Home Phone: Cell Phone: E-Mail Address: Birthdate: Age: Social Security Number: Patient s Employer: Male: Female:
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
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Patient Registration. First Name: Last Name: Middle Initial: Address: City, State, Zip: First Name: Last Name: Middle Initial:
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DENTAL QUESTIONNAIRE
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Tell Us About Your Child
GIVNG TREE PEDIATRIC DENTISTRY Rebekah Tannen DDS 110 Washington Avenue Pleasantville, NY 10570 Tel: 914-579-2225 Fax: 914-579-2226 Email: Team@givingtreedental.com www.givingtreedental.com We are thrilled
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