PATIENT INFORMATION DATE PATIENT INFORMATION INSURANCE INFORMATION PERSON TO CONTACT IN CASE OF EMERGENCY. r: No METHOD OF PAYMENT AUTHORIZATION

Size: px

Start display at page:

Download "PATIENT INFORMATION DATE PATIENT INFORMATION INSURANCE INFORMATION PERSON TO CONTACT IN CASE OF EMERGENCY. r: No METHOD OF PAYMENT AUTHORIZATION"

Carmella French
5 years ago
Views:

1 PATIENT INFORMATION DATE NAME MARRIED SINGLE MINOR MALE FEMALE LAST FIRST M SOCIAL SECURITY # ADDRESS BIRTHDATE STREET APT. # CITY STATE ZIP TELEPHONE MONTH DAY YEAR HOME WORK CELL NAME OF EMPLOYER ADDRESS IF FULL TIME STUDENT, SCHOOL NAME GRADE PERSON RESPONSIBLE FOR ACCOUNT - PLEASE CHECK ONE: 1.1. PATIENT GUARDIAN SPOUSE I_ FATHER MOTHER INSURANCE INFORMATION MINOR CHILD - MAY NEED TO COMPLETE BOTH BLOCKS FOR PARENT INFORMATION ADULTS - COMPLETE PRIMARY INSURED DUAL COVERAGE? ALSO COMPLETE SECONDARY INSURED PRIMARY INSURED / IF NO INSURANCE COMPLETE FOR RESPONSIBLE PARTY SECONDARY INSURED LAST FIRST M LAST FIRST M STREET CITY STATE ZIP STREET CITY STATE ZIP HOME WORK CELL HOME WORK CELL BIRTHDATE (MO/DAYIYEAR) RELATIONSHIP TO PATIENT BIRTHDATE (MO/DAY/YEAR) RELATIONSHIP TO PATIENT EMPLOYER DENTAL INS. CO EMPLOYER DENTAL INS. CO SS# SUBSCRIBER 4$ GROUP # SS# SUBSCRIBER # GROUP # PERSON TO CONTACT IN CASE OF EMERGENCY Name Address City/State/ZIP Telephone # AUTHORIZATION 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 payors and/or other health professionals by any method, including electronic transfer. Patient or Responsible Party Date State Driver's License # C- 4L STEPPING STONES TO SUCCESS' Has any member of your family ever been treated in our office? Yes r: No Whom may we thank for referring you to our office? METHOD OF PAYMENT Responsible party currently has an account with this office Li Yes NID Payment in full at each appointment (cash or personal check) Payment in full at each appointment ( VISA MC OTHER) Card # Exp. Date I wish to discuss the Dental Office's Financial Policy SERVICE CHARGE If I do not pay the entire new balance within days of the monthly billing date, a service charge will be added to the account for the current monthly billing period. The service charge will be a periodic rate of per month (or a minimum charge of $_ for a balance under ) which is an annual percentage rate of % applied to the last month's balance. In the case of default of payment, I promise to pay any legal interest on the balance due, together with any collection costs and reasonable attorney fees incurred to effect collection of this account or future outstanding accounts. PATIENT INFORMATION

PATIENT NAME DATE Primary reason for this dental appointment: Examination Emergency Consultation Dental History Please Circle Do you have a specific dental problem?

2 PATIENT NAME DATE Primary reason for this dental appointment: Examination Emergency Consultation Dental History Please Circle Do you have a specific dental problem? Describe Yes No Do you have dental examinations on a routine basis? Last visit Yes No Do you think you have active decay or gum disease? Yes No Do you brush and floss on a routine basis? Discuss Yes No Do your gums ever bleed? Discuss Yes No Do you like your smile? Why? Yes No Does food catch between your teeth? Any loose teeth? Yes No Do you want to keep your remaining teeth? Yes No Do you ever have clicking, popping or discomfort in the jaw joint? Do you brux or grind? Yes No Have your past experiences in a dental office always been positive? Yes No Do you smoke or chew? Any sores or growths in your mouth? Discuss Yes No Name of previous dentist (optional): Date of last full mouth x-rays (16 small films or panoramic): Medical History Are you under a physician's care now? Why? Who? Phone Yes No Have you ever been hospitalized or had a major operation? Discuss Yes No Have you ever had a serious injury to your head or neck? Discuss Yes No Are you taking any medications, aspirin, vitamins, herbals, pills or drugs? What? Yes No Are you on a special diet? Discuss Yes No Are you allergic to any medications or substances? Please check box below Yes No Aspirin 111 Penicillin Codeine Acrylic Metal Latex Rubber Milk Other Women (Please check): Pregnant/trying to get pregnant Nursing Taking oral contraceptives Discuss Yes No Do you now have or have you ever had any of the following? Do you take any of these medicines? Please check appropriate boxes. 'If yes to any of the starred conditions, please call prior to your appointment... premedication or changes in medication may be required. Yes No Yes No Heart Disease/Surgery* Excessive Bleeding Heart Murmur or Defect * C:.] Sickle Cell Disease Irregular Heart Beat Hemophilia Angina/Chest Pain Methemoglobinemia Heart Attack/Failure Leukemia Congenital Heart Disorder* Recent Blood Transfusion Mitral Valve Prolapse Swelling of Limbs Scarlet Fever Lung Disease LJ Rheumatic Fever * Breathing Problem 0 Artificial Heart Valve Shortness of Breath Heart Pace Maker' Frequent Cough Pulmonary Shunt"' Hay Fever High Blood Pressure Sinus Trouble Low Blood Pressure Asthma Bacterial Endocarditis* Bloody Sputum Unexplained Fever Emphysema Bruise Easily/Blood Disease Tuberculosis Anemia 1=1 Cancer Coronary Stent* X-Ray Treatments (Radiation) 0 Yes No Yes No Yes Chemotherapy Night Sweats Cold Sores Osteoporosis Yellow Jaundice Fever Blisters Bisphosphonates Kidney Problems Herpes Osteonecrosis of Jaw Renal Dialysis Stroke 0 Aredia I.V. Reclast I.V. Thyroid Disease Convulsions Zometa I.V. Parathyroid Disease Epilepsy or Seizures Fosamax, Actonel, Boniva Arthritis/Gout Fainting or Dizziness Stomach/Intestinal Disease Rheumatism Glaucoma Ulcers Pain in Jaw Joints Tumors or Growths Recent Weight Loss Cortisone Medicine E Nervousness Frequent Diarrhea Artificial Joint * Psychiatric Care Diabetes Sexually Transmitted Disease l Alzheimer's Disease Excessive Thirst AIDS Allergies (Medicines) Hypoglycemia HIV Positive Allergies (Pollen / Dust) Liver Disease Genital Herpes Hives or Rash Hepatitis A (Infectious) Drug Addiction/Alcoholism Need Premedication? Hepatitis B or C Tattoos/Body Piercing Ever taken fen-phenr Protease Inhibitor Sleep Apnea Cochlear implants? Have you ever had any other serious illness not checked above? Discuss Yes No Do you wish to talk to the dentist privately about any problem? Yes No To the best of my knowledge. all the preceding answers are correct. If I have any changes in my health status or it my medicines change I shall inform the dentist and staff at the next appointment without fail. X Date PATIENT SIGNATURE (PARENT OR GUARDIAN) Reviewed By Doctor Date BP Pulse History Review and Significant Findings 1: D ClO 1= :g Medical Updates I have read my MEDICAL HISTORY dated and confirm that it adequately states pass and present COI WILIUMS. DATE EXCEPTIONS PATIENTS SIGNATURE BP PULSE REVIEWED BY Dr Dr Dr Dr Dr Dr. WM. C- 113L STEPPING STONES TO SUCCESS* ,2007,2008 DENTAL AND MEDICAL HISTORIES - UPDATES

3 Patient Name: Date: PLEASE CHECK ALL DENTAL CONCERNS THAT APPLY TO YOU: TEETH: Broken or chipped Cracked Decayed Difficulty Chewing Discolored Food Trap Areas Grinding or Clenching Loose or Missing Filling Loose Tooth or Teeth Missing Tooth or Teeth Mouth Sores Sensitive to Temperature Changes Sensitive to Sweets Tooth Pain GUMS: Bleeding Pimple or Bump Sore or Sensitive JAW/FACIAL PAIN PROBLEMS: Facial Pain Frequent Headaches Jaw Clicks Jaw Pain Pain in Cheeks or Temples Other Concerns or Reasons for Visit: Here for a Periodic Examination. No specific Known Dental Problems. PAST DENTAL HISTORY: Last Dental Visit Dental Visit Frequency Ever: Months Years As Needed Have Tooth Replacement such as Dentures, Partials, Bridges or Implants? Other Patient Signature Date Page 1

4 LIST ANY MEDICATIONS WHICH HAVE CAUSED AN ALLERGIC REACTION: Antibiotics YES ONO Local Anesthetics YES ONO Aspirin YES ONO Metals YES ONO Codeine YES ONO Novocaine YES ONO Iodine YES ONO Penicillin YES ONO Latex YES ONO Plastic YES ONO Sedatives YES ONO Sulfa Drugs YES ONO Sleeping Pills YES ONO Other Allergens: LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING: Antibiotics YES ONO Heart Medication YES ONO Anticoagulants YES ONO Insulin YES ONO Blood Thinners YES ONO Muscle Relaxants YES ONO Blood Pressure YES ONO Pain Medication YES ONO Codeine YES ONO Sleeping Pills YES ONO Cortisone YES ONO Tranquilizers YES ONO Diet Pills YES ONO Digestive Aids YES ONO Other Current Medications: Patient Signature Date Page 2

5 BLAINE P. CUSACK, B.S., D.D.S. Clinical Director/ General Dentist American Academy of Pain Management Please list all your current medications/ supplements. Please, include the dosage thank you. American Board of Orofacial Pain Academy of Dental Sleep Medicine Credentialed by the Certification Board of the Academy of Dental Sleep Medicine Patient name Patient signature Date Comprehensive Dental Care for Head, Neck & Facial Pain, TM Disorders and Sleep Appliance Therapy / Biological Dentistry 475 W. 55th Street Suite 207 LaGrange, IL Phone: Fax:

6 MEDICAL HISTORY Anemia YES ONO Hepatitis YES ONO Arthritis YES ONO High Blood Pressure YES ONO Artificial Joint or Prosthetic YES ONO Immune Systems Disorder YES ONO Asthma YES ONO Kidney Problems YES ONO Bleeding Easily after a Cut 0 YES ONO Liver Problems YES ONO Cancer YES ONO Low Blood Pressure YES ONO Chronic Mouth Dryness YES ONO Osteoporosis YES ONO Current Pregnancy YES ONO Radiation Treatment YES ONO Depression YES ONO Respiratory Problems YES ONO Diabetes YES ONO Rheumaic Fever YES ONO Digestive Problems YES ONO Scarlet Fever YES ONO Dizziness YES ONO Sinus Problems YES ONO Epilepsy or Seizure YES ONO Tuberculosis YES ONO Headaches YES ONO Injury to: Heart Murmur YES ONO Face Mouth Heart Pacemaker YES ONO Neck Teeth Heart Palpitations YES ONO Heart Value Replacement YES ONO Heart Value Damaged YES ONO Other Medical History: DESCRIBE ANY SERIOUS ILLNESS, MAJOR SURGERY OR CONDITIONS NOT LISTED ABOVE: Date Description Patient Signature Date Page 3

7 ARE YOU UNDER A PHYSICIAN'S CARE? Practitioner Specialty Treatment & Approximate Date Primary Care Physician: IF THIS VISIT IS DUE TO ACCIDENT, PLEASE DESCRIBE: I authorize the release of a full report of examination findings, diagnosis, treatment program, etc., to any referring or treating dentist or physician. I additionally authorize the release of any medical information to insurance companies or for legal documentation. I understand that I am responsible for all fees for treatment regardless of insurance coverage. Patient Signature Date Page 4

8 BLAINE P. CUSACK, B.S., D.D.S. Clinical Director/ General Dentist American Academy of Pain Management American Board of Orofacial Pain Academy of Dental Sleep Medicine Credentialed by the Certification Board of the Academy of Dental Sleep Medicine Consent The undersigned hereby authorizes the Doctor to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize Doctor to perform any and all forms of treatment, medication, and therapy that may be indicated. I also understand the use of anesthetic agents embodies a certain risk. understand that my dental insurance is a contract between me and the insurance carrier, and not between the insurance carrier and the doctor and that I am still fully responsible for all dental fees. These fees are due and payable at the time service is rendered unless prior financial arrangements have been made. I also assign all insurance benefits to the doctor. Any payments received by the Doctor from my insurance coverage will be credited to my account, or refunded to me if I have paid dental feed incurred. I further understand that a late charge will be added to any overdue balance. I understand that where appropriate, credit reports may be obtained. PATIENT signature/parent/guardian Date DENTIST signature Comprehensive Dental Care for Head, Neck & Facial Pain, TM Disorders and Sleep Appliance Therapy / Biological Dentistry 475 W. 55th Street Suite 207 LaGrange, IL Phone: Fax:

9 BLAINE P. CUSACK, B.S., D.D.S. Clinical Director/ General Dentist Medical/ Dental Records Release American Academy of Pain Management American Board of Orofacial Pain Academy of Dental Sleep Medicine Credentialed by the Certification Board of the Academy of Dental Sleep Medicine I, the undersigned hereby authorize Dr. Cusack to release to, any and all of my medical/ dental information and records including office notes, medical charts, x-rays, MRI films, and letters received while under his care. Please forward any and all medical/dental records, MRI films, x-rays, etc. your facility has on file for me to. Dr. Blaine P. Cusack 475 W. 55th St. Suite 207 La Grange, IL Phone: (708) Fax: (708) Patient Name (print) Date Address SS# City, State, Zip Patient's Date of Birth x Patient Signature Witness Comprehensive Dental Care for Head, Neck & Facial Pain, TM Disorders and Sleep Appliance Therapy / Biological Dentistry 475 W. 55th Street Suite 207 LaGrange, IL Phone: Fax:

10 BLAINE P. CUSACK, B.S., D.D.S. Clinical Director / General Dentist PATIENT CONSENT FORM American Academy of Pain Management American Board of Orofacial Pain Academy of Dental Sleep Medicine Credentialed by the Certification Board of the Academy of Dental Sleep Medicine I understand that, under the Health Insurance Portability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the multiple health care providers who may be involved in that treatment directly and indirectly. Obtain payment from third-party payers. Conduct normal healthcare operations such as quality assessments and physician certification. I have been informed by you of your notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent. Patient Name Patient Signature Relationship to patient Date Comprehensive Dental Care for Head, Neck & Facial Pain, TM Disorders and Sleep Appliance Therapy / Biological Dentistry 475 W. 55th Street Suite 207 LaGrange, IL Phone: Fax:

11 American Academy of Pain Management American Board of Orofacial Pain Academy of Dental Sleep Medicine Credentialed by the Certification Board of the Academy of Dental Sleep Medicine BLAINE P. CUSACK, B.S., D.D.S. Clinical Director / General Dentist FINANCIAL TERMS AND CONDITIONS As a condition of treatment by Dr. Cusack and his office, I understand that financial arrangements must be in advance. The practice depends upon reimbursement from the patients for the costs incurred in that care and financial responsibility on the part of each patient must be determined before treatment. All emergency dental- medical services, performed without prior financial arrangements must be made in cash at the time services are performed. I understand that dental/ medical services furnished to me are charged directly to me and that I am personally responsible for payment of all dental/ medical services. If I carry insurance forms to assist in making collections from insurance companies. However, this office cannot and will not render services on the assumption that charges will be paid by an insurance company. A service charge of 1 1/2% per month (18% per annum) will be charged on the unpaid principle balance on all accounts not paid within 60 days of the treatment date. In consideration of the professional service rendered to me, or at my request, by Dr. Cusack and/ or his staff, I agree to pay the value of said services to the Doctor, or his assignee, at the time the service are rendered, or within (5) days of billing if credit shall be extended. I further agree for payment there for. Additionally, I agree that a waiver of any further terms or condition. I further agree that in the unlikely event that his office must institute collection proceedings with request to amounts owed by me for professional services rendered, this office shall be entitled to recover all costs incurred including and not limited to reasonable collection and or attorney fees. I grant my permission to you, or your assigned to telephone me at work to discuss any matter related to this form. I have read the above conditions, understood them and agree to their consent. Signed Date Relationship Witness Comprehensive Dental Care for Head, Neck & Facial Pain, TM Disorders and Sleep Appliance Therapy Biological Dentistry 475 W. 55th Street Suite 207 LaGrange, IL Fax:

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

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,