Patient Name Date of Birth. Address. City State Zip. Cell Phone Work Phone Home Phone . SSN Employer Name Employer Number.
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1 Waldrf Peridntics & Implants Amal Rastgi, DMD, MSD, PhD Cary Bly, DDS, MSD Bard Certified Specialists in Peridntlgy Hlly Lane #106 Waldrf, MD (F) PATIENT INFORMATION Patient Name Date f Birth Address City State Zip Cell Phne Wrk Phne Hme Phne SSN Emplyer Name Emplyer Number Referring Dentist SPOUSE, PARENT OR GUARDIAN INFORMATION Name Date f Birth Cell Phne Wrk Phne Hme Phne SSN Emplyer Name Emplyer Number PRIMARY INSURANCE INFORMATION Plicy Hlder Name Date f Birth Relatinship t Patient Emplyer Insurance Cmpany Phne: Address City State ID# Grup# SECONDARY INSURANCE INFORMATION Plicy Hlder Name Date f Birth Relatinship t Patient Emplyer Insurance Cmpany Phne: Address City State ID# Grup# PERSON TO CONTACT IN CASE OF EMERGENCY Name (utside f immediate husehld) Hme Phne ( ) Cell r Other ( )
2 Waldrf Peridntics & Implants Bard Certified Specialists in Peridntlgy Amal Rastgi, D.M.D., M.S.D., Ph.D. Cary Bly, D.D.S., M.S.D. Diplmates f the American Bard f Peridntlgy Medical Histry Patient Name: Date: Physician Name: Phne ( ) Date f last medical exam: Are yu nw r have yu recently been under a physicians care? Please explain: Have yu been hspitalized r had a serius illness? Please explain: Have yu ever had r d yu currently have the fllwing cnditins: Abnrmal Bleeding r Bruising HIV/AIDS Prlnged Bleeding Alchl r Drug Abuse Heart Prblems r Attack (date ) Psychiatric r Psychlgical Disrders Allergies Heart Murmur/MVP r Defect Radiatin Therapy Anemia Heart Valve Replacement (type ) Rheumatic Arthritis Hepatitis Shrtness f Breath r Chest Pain Asthma High Bld Pressure Sickle Cell Disease Bld Transfusin/Disease Jaundice Sinus Prblems Cancer r Chemtherapy Jint Replacement (date/s ) Strke/TIA (date/s ) Diabetes (circle type I r II) Kidney/Bladder Prblems Thyrid Prblems Emphysema Leukemia Tuberculsis Epilepsy/Seizures Liver Disease Ulcers Fainting Spells Lw Bld Pressure Unable t give bld Glaucma Lung Disease/Breathing Prblems Venereal Disease Hay Fever Osteprsis Other, please list Herpes Pace Maker (date ) D yu snre, have sleep apnea, use a CPAP r ral appliance? D yu use narctics? Please describe: Have yu ever had t pre- medicate prir t a dental appintment? Please describe: Are yu taking any medicatin regularly? (ver the cunter medicatin, supplements, herbs, vitamins, birth cntrl, shts, implant/patch, hrmne therapy, inhalatin, etc.) Please list: Check any f the fllwing that yu are taking r have taken in any frm: Crtisne r Sterids Sedatives Fsamax, Bniva, Actnel Reclast Infusin Prlia(Densumab) Bld Thinners Tranquilizers Bisphsphnates Osteprsis Medicatin Fen/Phen r Redux Are yu allergic t r d yu suffer ill effects frm any f the fllwing? Penicillin Cdeine Sulfa Drugs Ibuprfen Aspirin Husehld Bleach Sulfites Valium Metals Dental Anesthesia Latex Prducts Other D yu smke r use tbacc? YES NO If yes, hw much fr hw lng? If female: Are yu pregnant? YES (mnth ) NO Are yu breast feeding? YES NO The abve infrmatin is true t the best f my knwledge. Signature Date
3 Waldrf Peridntics & Implants Bard Certified Specialists in Peridntlgy Amal Rastgi, D.M.D., M.S.D., Ph.D. Cary Bly, D.D.S., M.S.D. Diplmates f the American Bard f Peridntlgy Dental Histry Patient Name: Date: Dentist s Name: Phne ( ) Date f last cleaning and exam: Have yu ever had r d yu currently have the fllwing cnditins r prcedures: Acid Reflux Anrexia/Bulimia Crwns r bridges Bad breath r taste Bipsy Biting f lips r cheeks Bleeding when brushing/flssing Clenching r grinding f teeth Cld sres Cmplicatins t dental anesthetics Dental implants Dentures (cmpete r partial) Dry muth Dry scket Ear aches, headaches, neck pains Fd catching between teeth Gum bil Lse teeth Orthdntic treatment (braces) Pain in jaws Pain n biting Ppping r clicking f jaws Prlnged bleeding after extractins Radiatin t head r neck Recessin f gums Rt canal treatment Sensitivity t ht, cld, r sweets Sres r ulcers in muth Swelling f gums Teeth that have mved Thrush TMJ/rthgnathic (jaw) surgery TMJ/TMD Trauma t the head, neck, r teeth Weight lss surgery Widening f spaces Hw ften d yu brush yur teeth? D yu use flss? Hw frequently? D yu use any ther ral hygiene aids? Hw frequently d yu have prfessinal cleanings? D yu wear an cclusal guard/night guard? Have yu ever had any peridntal (gum) treatment? Have yu ever had a scaling and rt planing (deep cleaning)? YES NO Date: Have yu ever had any cmplicatins related t dental treatment r dental anesthesia? Are yu fearful abut dental treatment? YES NO Were yu referred by yur dentist? YES NO If s, what fr? What is the reasn fr yur visit tday? The abve infrmatin is true t the best f my knwledge. Signature Date
4 Waldrf Peridntics & Implants Amal Rastgi, DMD, MSD, PhD Cary Bly, DDS, MSD Bard Certified Specialists in Peridntlgy Hlly Lane #106 Waldrf, MD (F) TREATMENT AUTHORIZATION I hereby authrize Waldrf Peridntics & Implants, Drs. Rastgi & Bly, t administer such medicatins and perfrm such diagnstic, therapeutic and surgical prcedures as may be necessary fr prper dental care. I certify that I have read and understand all the questins n these patient registratin, health histry, and dental histry frms. The infrmatin prvided in the medical/dental histries is true t the best f my knwledge. I als understand it is very imprtant t reprt any changes in my medical r dental status t my prvider at the earliest pssible time, and I agree t d s. I understand that prviding incrrect infrmatin can be dangerus t my verall health and affect the result f treatment. Signature Date PAYMENT AUTHORIZATION I hereby authrize payment directly t Waldrf Peridntics & Implants, Drs. Rastgi & Bly f the grup insurance benefits therwise payable t me. Due t the cnstantly changing insurance rules and regulatins, benefits and deductibles, the Dental Office is nly able t apprximate yur ut- f- pcket expenses fr dental treatment. Yur dental insurance benefits are based upn a cntract between yu r yur emplyer and the insurance cmpany, nt ur ffice. If yur insurance pays mre than expected yu will be credited the difference. I understand that if payments are nt received by the agreed upn dates, a finance charge may be added t my accunt after 90 days f the date f service in additin t any cllectin r attrney fees. I authrize the use f my scial security number t file my dental claim and understand that if ne is nt prvided t the ffice, payment in full will be cllected at each visit. Payment is expected at time f service and cancellatin r failure t keep a scheduled appintment withut a 48 hur ntice may result in a charge fr the time reserved fr yu. It is imprtant fr yu t understand that yu are persnally respnsible fr all charges that yu r a dependent may incur in this ffice. I understand and accept final respnsibility fr all csts incurred. Signature Date
5 ACKNOWLEDGEMENT OF PRIVACY PRACTICES Waldrf Peridntics & Implants Hlly Lane, Suite 106 Waldrf, MD My signature cnfirms that I have been infrmed f my rights t privacy regarding my prtected health infrmatin. I understand that this infrmatin can and will be used t: Prvide and crdinate my treatment amng a number f health care prviders (e.g. my dentists and physicans) wh may be invlved in that treatment directly and indirectly Obtain payment frm third-party payers (e.g. my insurance cmpanies) fr my health care services Cnduct nrmal health care peratins such as quality assessment and imprvement activities I have been infrmed f my dental prvider s Ntice f Privacy Practices cntaining a mre cmplete descriptin f the uses and disclsures f my prtected health infrmatin. I have been given the right t review and receive a cpy f such Ntice f Privacy Practices. I understand that my dental prvider has the right t change the Ntice f Privacy Practices and that I may cntact this ffice at the address abve t btain a current cpy f the Ntice f Privacy Practices. I understand that I may request in writing that yu restrict hw my private infrmatin is used r disclsed t carry ut treatment, payment r health care peratins. Patient Name: Date: Signature: Relatinship t Patient: Dependent family members als cvered by this acknwledgement: Fr Office Use Only: We were unable t btain the patient s written acknwledgement f ur Ntice f Privacy Practices due t the fllwing reasn: The patient refused t sign Cmmunicatin barriers Emergency situatin Other
Medical History. Yes or No
Medical Histry Althugh dental persnnel primarily treat the area in and arund yur muth, yur muth is a part f yur entire bdy. Health prblems that yu may have, r medicatin that yu may be taking, culd have
**Parent/Guardian Information for Minor Children. Information for Military Members. Referral Information
Patient Infrmatin Tday s date: Patient Name: I prefer t be called Last First MI Address: Street Apartment # City State Zip Cde Sex: Male Female Check ne: Minr child** Single Married/Partnered Patient s
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Patient Name: Address City State Zip Code. H. Phone W. Phone Cell Phone
Name yu prefer t g by: Address City State Zip Cde H. Phne W. Phne Cell Phne Email Address: Sex: M F Date f Birth Age Marital Status: M S D W Spuse s Name if Married: Scial Security # Referred by: Persn
Street Address: City: State: Zip: Home Ph: Cell Ph: SSN#: Name: Relationship to Patient: Address: City: State: Zip: Home Ph: Cell Ph:
PATIENT INFORMATION Name: Birthdate: Street Address: City: State: Zip: Hme Ph: Cell Ph: Email: SSN#: Sex (circle) M F Emplyer Name & Phne #: PARENT/GUARDIAN INFORMATION (IF UNDER THE AGE OF 18) Name: Relatinship
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Welcme t A very warm welcme t yu! The entire team wuld like t thank yu fr selecting ur ffice t care fr yur dental needs. We are a family-riented dental practice lcated n the suthwest crner f Furteen Mile
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Patient s Last Name: First Name: Address: City: State Zip Phne: (Hme) (Wrk): (Cell): Age f Birth / / Email: Occupatin Referred by: Patient s cnditin: Duratin f Prblem: Dctr: Dctr s Telephne: N. in husehld
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Last: First: MI: Nickname:
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List the health concerns that brought you into this office
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