JOSEPH A SILVAGGIO, DMD KRISTIN M JABBAS, DMD BILAL CHAUDHRY, DMD

Transcription

1 PLEASE ANSWER EACH AND EVERY QUESTION THE JOSEPH A SILVAGGIO, DMD KRISTIN M JABBAS, DMD BILAL CHAUDHRY, DMD Front and back sides of this form IT IS IMPORTANT TO INCLUDE all information we are requesting, especially MEDICATIONS, VITAMINS AND SUPPLEMENTS you may be talking at this time. DATE: Patient Name: Address: City: State: Zip: Sex: Marital Status: Home Phone: Work Phone: Cell Phone: Social Security No: Birth Date: Age: Occupation: Employer: General Dentist: Who referred you? Have you ever been treated by our doctors? PLEASE READ THE FOLLOWING CAREFULLY: The information contained on this form s correct, to the best of my knowledge. I agree to be responsible for all fees related to my visits here, including any returned check charges, as displayed. I allow release of all of my information to my dentists/doctors, as required by them.

2 Signature: (If Patient is a minor, parent/ guardian must sign) Parent/Guardian Info for minors under 18 yrs old: Name: Soc. Sec.No: Birth Date: Phone/Address if different from minor s: PLEASE FILL IN EACH SECTION with your DETAL INSURANCE INFORMATION PRIMARY CARRIER: Insurance Carrier Name: Employer: ID #/ Soc. Sec.# If Subscriber is NOT the patient, please fill in: Subscriber Name: Subscribes Address: Subscriber ID#/Sic. Sec# Subscriber Date of Birth: Relationship to patient: If Patient is a full-time college student: College: College City & State: SECONDARY CARRIER: Insurance Carrier Name: Employer:

3 Subscriber Name: Subscriber Address: Subscriber ID#/Sic. Sec# Subscriber Date of Birth: Relationship to patient: PLEASE CIRCLE ANY OF THE FOLLOWING WHICH YOU HAVE OR HAVE HAD IN THE PAST: Heart trouble Heart Mummur Mitral Valve Prolapse Rheumatic Fever Angina High Blood Pressure Epilepsy Asthma Paget s Diseases Low Blood Pressure Stroke TIA Multiple Myeloma Congenital Heart Diseases Diabetes Anomia Osteogenesis Imperfection Thyroid Diseases Tuberculosis Arthritis Primary Hyperparathyroidism Lung Disease Radiation Treatment Convulsions Herpes Hepatitis A B or C Glaucoma Psychiatric Treatment Ulcer Kidney Disorder Migraine Sinus Conditions Blood Disorders Fainting Spells Venereal Disease MS Breast Cancer/Mastectomy Osteoporosis Other: PLEASE CIRCLE ANY OF THE FOLLOWING TO WHICH YOU ARE ALLERGIC OR HAVE HAD AN UNUSUAL REACTION TO: Latex Novocaine Xylocalne Eplnephrine Peniclline Amoxicllin Sulfa Drugs Codeine Demerol Sedatives Barbiturates Erythromycin Steroids Other: GENERAL HEALTH:

4 1) Excellent Good Fair Poor 2) If you are under the care of a physician a this time for other than regular check-ups please explain: Name of caring physician 3) Do you need to premedicate prior to dental treatment? (It is necessary for some patients to take large dose antibiotics ine hour prior to dental treatment, due to mummur mitral valve, or prolapse or artificial joints) 4) LIST THE NAMES OF ALL prescribed and non-prescribed medications, vitamins, supplements and drugs you are taking today: 5) Are you taking or have you taken in the past 10 years any Bisphosphonates?(EX: Actonel, Aldronate, Aredia, Boniva, Didronel, Fosamax, Reciast, Skellid, Zometa) If yes, which one? 6) Are Wearing a pacemaker or heart valve prosthesis? 7) If you have been hospitalized or had a serious illness in the past five years, please explain: 8) Have you ever been diagnose as having HIV or AIDS? 9) Have you ever had abnormal bleeding associated with previous extractions, surgery, or trauma? 10) Have you pregnant? If so, how far along? 11) Have you ever undergone endodontic treatment (root canal therapy or apical surgery)? 12) What symptoms are you experiencing today? 13) Is there any other information we should know about you health or teeth.?

5 SILVAGGIO ENDODONTICS Joseph A. Silvaggio, DMD PC INFORMED CONSENT FOR END000NTIC TREATMENT (PA state law requires a consent form prior to endodontic treatment) Before starting endodontic treatment (root canal therapy, apicoectomy, etc.), you should be informed of all risks and alternatives to endodontic treatment. You will be required to sign this consent prior to the initiation of treatment. However, it does not commit you to treatment. This consent serves to acknowledge that you have been informed and understand the following. Endodontic treatment is an attempt to retain a tooth, which may otherwise require extraction. I understand that it is a process involving removal of tissues in the center of the tooth (the root canal) and the sealing of the space that is created during the process of removal and cleansing of the root canal system. I further understand that the root canal treatment may fail, if proper restoration of the tooth is not completed after the root canal treatment is done, and that such restoration is a separate and distinct procedure with an additional fee. Although root canal therapy has a high degree of success, it cannot be guaranteed. The doctor will exact his professional training to achieve success and avoid or minimize complications listed below. initial root canal treatment success can be as high as 90%. Occasionally, a tooth, which has had root canal therapy, may require retreatment, microsurgery, or extraction. Retreatment and surgical success rates are approximately 70%. The alternatives to endodontic treatment include no treatment, waiting for more definitive development of symptoms, and extraction of the tooth. I understand the risks of no treatment include, but are not limited to, infection, swelling, cyst formation, pain and loss of tooth/teeth and/or systemic disease. Risks of endodontic treatment are of two kinds those risks associated with general dental procedures (as in any dental office), and those risks specific to endodontic treatment (in this office). Risks of general dental procedures include, but are not limited to, complications resulting from the use Of dental instruments, drugs, sedation, medicines, analgesics (pain killers), anesthetics, and injections. These complications include pain, infections, swelling, bleeding, sensitivity, numbness, and tingling sensation (transient or permanent) in the lips, tongue, chin, gums, cheek, and teeth, thrombophlebitis (inflammation to the vein), reaction to injections (including a temporary rapid heartbeat), change in occlusion (biting), muscle cramps and spasms, temporomandibular (jaw) joint difficulty, loosening of teeth or restorations in teeth, injury to other tissues, referred pain to the ear, neck, and head, nausea, vomiting, allergic reactions, itching, bruises, delayed healing, sinus complications and further surgery. Prescribed medication and drugs may cause drowsiness and lack of awareness and coordination (which may be influenced by the use of alcohol and other drugs). Therefore, it is advisable not to operate any vehicle or hazardous device, or to work for twenty a four hours or until recovered from their effects. Antibiotics may interfere with oral contraceptives and caution should be used during antibiotic use. Risks specific to endodontic therapy include instruments broken within the root canal(s), perforations (extra openings) of the crown or root of the tooth, damages to bridges, existing fillings, crowns or porcelain veneers, loss of tooth structure in gaining access to canals and fracture of tooth structure, and change in tooth color (becoming darker than adjacent teeth). During treatment, complications may be discovered which make treatment impossible, or may require microsurgery, or etraction. These

6 complications may include blocked or obstructed canals resulting from fillings, prior treatment, natural calcification, broken instruments, curved roots, periodontal disease (gum disease), and cracks or fractures of the teeth. If you are scheduled for surgery, the risks specific to it involve an incision into the gingival tissue (gums). Any incision into the gums carries the inherent risks of swelling, bruising, scar formation, recession of the gum lines, numbness, which could be temporary or permanent, and possible infection. A surgical procedure (most commonly called an apicoectomy) may also involve the removal of infected bone tissue and root tip of the tooth/teeth. In addition to the risks mentioned above) further complications include, but are not limited to, post-operative pain, bleeding, swelling, infection, bruising of the gums and face, damage to adjacent teeth, temporary or permanent numbness or tingling of the lip, chin, tongue or other areas, and perforation into the sinuses. I HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. BY MY SIGNATURE BELOW, t CONSENT TO THE TREATMENT DESCRIBED IN THIS PAPER. Patient s Signature: Date: (Parent/Guardian must sign, if patient is a minor) Witness Date:

7 SILVAGGIO ENDODONTICS Joseph A. Silvaggio, DMD PC ACKNOWLEDGEMENT OF RECEIPT OF NOTICE AND CONSENT TO USE AND DISCLOSE HEALTH INFORMATION Date This acknowledgement of notice and consent authorizes Joseph A. Silvaggio, DM13, PC to use and disclose health information about you and your treatment, payment, and healthcare operations purposes. This practice has a Notice of Privacy Practices, which describes how we may use and disclose your protected health information and how you can access your protected health information and exercise other rights concerning your protected health information. Please ask at the front desk if you desire to read or obtain the full privacy notice. I, (print name), am aware of and/or received a copy of this practice s Notice of Privacy Practices and authorize them to use and disclose health information for treatment, payment, and healthcare operations purposes consistent with its Notice of Privacy Practices. Signature of Patient (or parent/guardian if patient is a minor) Printed Name of Minor Patient Relationship to Patient ************************************************************************************* Please fill in the EMERGENCY CONTACT PERSON. Also fill in ALL NAMES OF THOSE WITH WHOM WE CAN DISCUSS YOUR TREATMENT, PAYMENTJ OR HEALTHCARE OPERATIONS. It is not necessary to include your dentist/referring dentist, as t is understood that he/she would be included to receive your treatment, payment, or healthcare operations information. Emergency Contact Relationship to Patient Phone Number Responsible Party Relationship to Patient Phone Number Emergency Contact Relationship to Patient Phone Number Emergency Contact Relationship to Patient Phone Number CAN WE CALL YOU OR LEAVE A MESSAGE FOR YOU AT THESE IF YES, please put an X on the line. If you fill n OTHER, specify the number and who we are calling. Home Answering Machine Work/voic

8 Cell/Cell Voic Pager Fax Other-Specify Other-Specify

9 S.ILVAGGIO ENDODONTICS Joseph A. Silvaggio, DMD PC NOTICE OF PRIVACY PRACTICES THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. - PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health information, We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it s in effect. This Notice takes effect (4/14/03), and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. For example: Treatment: We may use or disclose you health information to a physician, dentist or other healthcare provider. providing treatment to you. Payment: We may use and disclose your health information to obtain payment or preauthorization for services we provide to you. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities. Some examples of healthcare operations that this office may use are: calling you

10 by name in the waiting room, discussing your health information, treatment. Follow up treatment, payment and/or preauthorization information at the front desk. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not effect any use or disclosures permitted by your authorization while it was in effect Unless you give us a written authorization. we cannot use or disclose your health information for any reason except those described in this Notice. To your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that s directly relevant to the person s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization. Required By Law: We may use or disclose your health information when we are required to do so by law. This information can be given to health oversight. agencies. Also, we may disclose your health information to a person who may have been exposed to a communicable disease or may otherwise be at risk of contracting or spreading the disease or condition. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others. National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances. Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voic messages, postcards, or letters).

11 PATTENT RIGHTS Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies arid staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge our current fee for staff time to locate and copy your health information, and to cover postage to send the copies to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.) Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatments payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, If you request this accounting more than once in a 12- month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but ifwe do, we will abide by our agreement ( except in an emergency). Alternative Communication: You have the right to request that we communicate with you about health information by alternative means or to alternative locations. {You must make your request in writing} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. Electronic Notice: If you receive this Notice on our Web site or by electronic mail ( ), you are entitled to receive this Notice in written form. QUESTIONS AND COMPLAINTS If you want more information about our privacy practices or have questions or concerns please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You may also submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint

12 with the U.S. Department of Health and Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or the U.S Department of Health and Human Services. Contact Officer: Karlene Kipp Telephone: (610) Fax: (610) Address: 415 Business Park Lane Allentown, PA