Cranberry Dental Assoc. Inc. 70 North Main Street Carver, MA Patient History. Name: Date of Birth: Address: City:

Transcription

1 Cranberry Dental Assoc. Inc. 70 North Main Street Carver, MA Patient History Name: Date of Birth: Address: City: State: Zip: Address: Home: Cell: Work: Dental Insurance: Subscriber Name: Subscriber Date of Birth: Group #: Marital Status: Name of Spouse/Partner: Date of Birth: Home: Cell: Work: **Person to call in case of emergency** Name: Phone: Relationship to you? 1

2 Circle the Appropriate Answer Yes No Is your general health good? Yes No Has there been a change in your health within the last year? If Yes Yes No Have you had any surgeries, been hospitalized or had serious illness in the last 3 years? If yes, why? Name of Physician Yes No Are you being treated by a physician now? For What? Date of last dental exam? Date of last medical exam? Yes No Are you in pain now? HAVE YOU EXPERIENCED: Yes No Chest Pain (angina)? Yes No Dizziness? Yes No Swollen Ankles? Yes No Ringing in ears? Yes No Shortness in breath? Yes No Headaches? Yes No Recent weight loss, fever, night sweats? Yes No Fainting spells? Yes No Persistent cough, coughing up blood? Yes No Blurred vision? Yes No Bleeding problems, bruising easily? Yes No Seizures? Yes No Sinus problems? Yes No Excessive thirst? Yes No Difficulty swallowing? Yes No Frequent urination? Yes No Diarrhea, constipation, blood in stools? Yes No Dry mouth? Yes No Frequent vomiting, nausea? Yes No Jaundice? Yes No Difficulty urinating, blood in urine? Yes No Joint pain, stiffness? DO YOU HAVE OR HAVE YOU HAD: Yes No Heart disease? Yes No AIDS/HIV? Yes No Heart attack, heart defects? Yes No Tumors, cancer? Yes No Heart murmurs? Yes No Arthritis, rheumatism? Yes No Rheumatic Fever? Yes No Eye disease? Yes No Stroke, hardening of arteries? Yes No Skin disease? Yes No High blood pressure? Yes No Anemia? Yes No Asthma,TB, emphysema, other lung diseases? Yes No VD (syphilis or gonorrhea) Yes No Hepatitis, other liver disease? Yes No Herpes? Yes No Stomach problems, ulcers? Yes No Kidney, bladder disease? Yes No Diabetes? Yes No Thyroid, Adrenal disease? Yes No Family History of diabetes, heart problems, tumors? Yes No Psychiatric care Yes No Pacemaker? Yes No Radiation treatments/chemotherapy? Yes No Contact lenses? Yes No Prosthetic heart valve? Yes No Artificial joint? Yes No Blood transfusions? ARE YOU TAKING: Yes No Recreational drugs? Yes No Tobacco in any form? Yes No Medications, over the counter meds Yes No Alcohol? including aspirin, natural remedies? ALLERGIES: PLEASE LIST MEDICATIONS PRESENTLY TAKING: Do you have or have you had any other diseases or medical problems NOT listed on this form? Is there anything else you would like us to know about yourself? To the best of my knowledge, I have answered every question completely & accurately. I will inform my dentist of any changes in my medical history/meds. WOMEN ONLY: Yes No Are you or could you be pregnant or nursing? Yes No Taking birth control pills? Patient Signature: Date: Dentist Signature: Date: 2

3 CRANBERRY DENTAL ASSOCIATES 70 N. MAIN STREET CARVER, MA DENTAL HISTORY Reason for this visit? Date of last dental treatment? Last Dental X-Rays Previous Dentist Address How often have you had examinations in the past? Have you had Date Dentist Periodontal Treatment? Root Canal Treatment? Orthodontic Treatment? What is your usual daily mouth care? Is your toothbrush (circle): Hard, Medium, Soft, Sonicare, Oral B? Are your teeth easy to floss? Or does it shred and tear? Do you use the following (circle): Fluoride Rinses, Stimulants, Water Pik, Salt, Peroxide,Baking Soda? When you smile, are you pleased with the way you look? What would you like to change about your smile appearance? Have you noticed the following: (check) Yes No Teeth sensitive to hot or cold? Teeth tender to chew on or touch? Food catching between teeth? Gums bleeding after brushing? Swellings or lumps in your mouth? Unpleasant breath or bad taste? Grinding or clenching? Does your jaw joint make noises when opening wide or chewing? Have you had any unfavorable dental experiences? Does your jaw joint bother you if you keep it open for a long period of time? Are you familiar with the following? (check) Yes No Rubber Dam? Relaxation Techniques? Nitrous oxide analgesia? (laughing gas) Cosmetic Dentistry-Bonding 3

4 Cranberry Dental, Associates Inc. 70 North Main Street Carver, Mass OFFICE POLICY AND CONSENT FOR DENTAL CARE: 1. We invite you to discuss with us any questions regarding our services. The best dental health care is based on a friendly, mutual understanding between provider and patient. 2. For those patients who are aided by a dental insurance plan, we will process the forms for you and submit pretreatment estimates when appropriate; however, you are responsible for deductibles and co pays at the time services are rendered. We try to estimate the patient balance as closely as possible, but insurance companies do have fee schedules that may differ from ours. The patient will be billed for any amount not covered by the insurance. Our office manager will be happy to answer any questions you may have regarding your statement. Please remember that the patient or parent remains legally responsible for all charges incurred regardless of whether or not the insurance pays any portion of the treatment. Each time a payment is received from your insurance company, our computer system will generate a patient statement if there is any balance due. Since insurance companies generally take days to process a claim, we would appreciate prompt payment. Any patient portion billed and outstanding for a period greater than 60 days will be subject to an interest charge of 18% per annum (1.5% per month) 3. I understand that the information that I have given today is correct to the best of my knowledge and that this information will be held in the strictest of confidence. 4. I understand that it is my responsibility to inform this office if there are any changes in my (or my child s) medical history, medication, or treatments. It is also my responsibility to inform this office of any change of address, phone or dental insurance. 5. I authorize the dental staff to perform any necessary services, with my informed consent that my self or my child may need during diagnosis and treatment. I will not hold my dentist or any other member of his staff responsible for any errors or omissions that I may have made in the completion of this form. 6. I understand that if I miss an appointment without notifying the office within 48 hours, they may charge me $75.00 for the broken appointment. A broken appointment fee must be paid before any other appointments can be scheduled. 7. I understand that no child will be seen unless accompanied by a parent or guardian. We also recommend that you remain in the office for the duration of the appointment. 8. I understand that this authorization will cover all aspects of routine dental care including, but not limited to, the administration of local anesthesia; the taking of x-rays and photographs; cleaning and scaling of the teeth; root canal therapy; fitting of crowns, bridges and dentures; periodontal treatment; minor surgical procedures; the fabrication of a night guard, sports guard, or space retainer; preventative services, such as application of fluoride ; bleaching procedures; composite filings. This authorization shall remain in effect for the present visit and subsequent visits during the course of continued treatment in the office. By signing this policy letter, you agree to the financial terms of this office and authorize us to submit and collect for insurance benefits otherwise payable to you. Patient s/parent of Patient Signature Date Parent Social Security # (for identification purposes only) 4

5 Appointment/ Cancellation Policy Reminder We ask that you read the following and acknowledge your acceptance below. At Cranberry Dental Associates, we value each and every patient and their time. We correspondingly expect that our patients realize and appreciate the value and importance of the appointment time that is scheduled specifically for you with our doctors and hygienists. I am sure that you have experienced at some time in your life an arduous delay when waiting to see your medical or dental provider. Although, we make every effort to see you promptly at the appointed time there may be some rare occasions when due to an emergency treatment that you will experience some minor delay. Be assured however that if and when the situation is reversed and you require urgent care you will be provided with a similar priority treatment. Our respect for our patients time and concern for their comfort is always foremost in our minds. If for any reason we should fall short of your expectations, please advise us so that we can learn from your experience and correct the situation. The Cranberry Dental appointment cancellation policy requires that patients provide us with a 48 hour notice, if because of serious and unavoidable circumstances which are beyond their control they are compelled to cancel their appointment. Fortunately, most of our patients respect the Doctors time and provide us with the required notice or sufficient notice so that we are able to refill the doctors /hygienists schedule however a few do not and seem to be plagued by constant emergencies all which occur at the last minute. The result is that these people have caused not only a financial hardship on the practice but prevented our other responsible patients from receiving the treatment that they so desperately need and deserve. Because of this, we are instituting immediately a $75.00 cancellation fee for those patients who fail to give us the time necessary so that we can replace the appointment. Please be assured that we will be understanding if a true emergency arises which makes your attendance impossible. At Cranberry Dental we have taken extraordinary measures to provide you with the highest quality care available. In the past year, countless patients have benefited from our emergency service and coverage, a service which is available after hours and weekends and is not available at most other dental offices. Please understand that the $75.00 fee does not adequately cover the loss the practice incurs when a patient fails to provide the required notice or even worse no shows for the appointment. Patients therefore who pay the fee but continue to cancel their appointments will be asked to leave the practice. Fortunately for us, most of you do not fall into this category and therefore rarely if ever will be affected by this necessary strict adherence to a long standing policy. Patient/Parent of Patient Acknowledgement and Agreement Date 5

6 CRANBERRY DENTAL ASSOCIATES NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT OF RECEIPT The Cranberry Dental Associates Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. A copy of our Notice of Privacy Practices is available at our office. I acknowledge that I have received the Notice of Privacy Practices. Signature of Patient or Patient s Representative Date Print Name Relationship to Patient Name of Interpreter (if applicable) If written acknowledgement is not obtained, please check reason: Notice of privacy Practices Given-Patient unable to Sign Notice of Privacy Practices Given-Patient Declined to Sign Other Signature of Cranberry Dental Associates Representative Date Print Name Title 6

7 CRANBERRY DENTAL ASSOCIATES Frank Skip Wetherbee, DMD Jill Park, DMD Some of you may not be aware of the Amalgam (silver filling) controversy that exists, not only in the USA but around the world. In a nutshell, the dental amalgam filling material is made up of approximately 50 % mercury in a compound that supposedly does not allow toxic mercury into the human body. There are many who don t believe this. To start with, it is a known fact that chewing releases mercury vapors even from old fillings. Add to that the fact that in both Japan and Sweden dentists are not allowed to use this material (by law) as disposal of the scraps can lead to mercury seeping into the ground water and you really have to wonder For the above reasons, and more, we do not utilize mercury filling material in our office. We use composite (tooth colored) material exclusively for all restorations. In addition to the above concerns we are among a large and growing group of dentists that feel the composite materials (now in their 8 th generation of development) are superior to mercury fillings for many reasons. How does this affect you? All insurance companies do not consider composite filling materials in back teeth in the same light. Some cover them as they would silver, some pay less and still others won t cover them at all. We encourage you to discuss this with your carrier. They will not change these policies unless sufficient numbers of those paying the premium (you) make themselves heard. In the meantime, if you are scheduled for a filling on a back tooth your insurance coverage may be different than it would be for a mercury filling. I have read, and I understand the above: Signed: Date: For more detailed information we suggest you go to and/or Google Amalgam Fillings. 7