Welcome to our Practice

Transcription

1 Welcome to our Prctice PATIENT INFORMATION: Mr. Mrs. Ms. Dr. First Nme_ Sex: Mle Femle Street Home. Referred By Dentist. Driver's Lic.# Employer. Birth Dte In cse of emergency, plese contct..cell.i..m.i.. Age Soc. Sec. # City- Orthodontist-.Apt._ -Nerest reltive not living with you _ Bus. Tel.( ) WHO WILL BE RESPONSIBLE FOR YOUR ACCOUNT: Self (If self, skip this section) Spouse Fther Mother Other_ -Lst Nme E-miL Tody's Dte -Stte-..Zip. Hve you ever been ptient of our prctice?. Hs fmily member ever been ptient of our prctice? Medicl Dr Personl Pyment Type: Csh Check Credit Crd Tel. ( ) Reltion Nme S.S.#.. Birth Dte. Age..Cell.. E-mil. Driver's Lic.#.. Employer.- Bus. Tel.I SPOUSE OR OTHER GUARANTOR INFORMATION: (IF DIFF, Street - Tel. ( > INSURANCE INFORMATION:. Reltion -.Apt City_ -S.S.# -Employer-. Bus. )_ Student:. Full Time Prt Time t School Nme nd SCHOOL NAME Mritl Sttus:. Mrried Divorced Widow 3 Single Leglly Seprted C TY.Birth Dte. - Stte - -Zip Employed:.... Full Time Prt Time Retired t Do you belong to PPO or HMO? PRIMARY DENTAL INSURANCE COMPANY: Bus. ADI Bus. Ins. Co. Nme. Group #. Reltion.. _Pln_.Group Nme. I.D. #_ Insured Prty. Birth Dte Sex: M F Tel.' itrte SECONDARY DENTAL INSURANCE COMPANY: Employer Bus. _ ADI Bus. Ins. Co. Nme. ADDRESS Group # Reltion ) ^^.Pln -Group Nme.. I.D. #_ -Insured Prty. Birth Dte Sex: M F PRIMARY MEDICAL INSURANCE COMPANY: Employer Bus. _ Al Bus. Tel.( Ins. Co. Nme. ADDRESS Group # Reltion S.S.# ).Group Nme..I.D. #_ -Insured Prty_. Birth Dte Sex: M F ) SECONDARY MEDICAL INSURANCE COMPANY: Employee Bus. ^ AD Bus. Ins. Co. Nme. Group #. Reltion. Street.. Apt City Stte_ -Zip- Nme- Employer- -Pln- - -Pln..Group Nme. -I.D. #_.Insured Prty_. Birth Dte Sex: M F -.

2 HEALTH HISTORY: To our ptients: Although orl surgeons primrily tret the re in nd round your mouth, your mouth is pn of your entire body. Helth problems tht you my hve, or medictions tht you my be tking, could hve n importnt interreltionship with the cre tht you will be receiving. Thnk you for nswering the following questions. Your nswers re for our records only nd will be considered confidentil. Reson for tody's office visit?_ Height-.Weight. Are you in good helth?. Hve there been ny chnges in your generl helth in the pst yer?. Are you under the cre of physicin? If so, for wht re you being treted? Hve you hd ny illness, opertion or been hospitlized in the pst five yers? If so, describe Dte of lst visit _ Do you hve unheled / recurrent injuries or inflmed res, growths or sore spots in or round your mouth? If so, describe where Do you hve prosthetic joint / implnt? If so, describe where - Hve you hd hert vlve replcement or vsculr grft? Hve you, or fmily member, hd ny unusul or serious rections to generl nesthesi? Hs physicin or previous dentist recommended tht you tke ntibiotics prior to your dentl tretment? HAVE YOU HAD, OR DO YOU CURRENTLY HAVE: YES NO 10. Rheumtic fever? 1 1. Dmged hert vlves / mitrl vlve prolpse? 12. Hert murmur? 13. High blood pressure? 14. Low blood pressure? 15. Chest pin /ngin? 16. Hert ttck(s)? 1 7. Irregulr hert bet? 18. Crdic pcemker? 19. Hert surgery? 20. Pneumoni, bronchitis, chronic cough? 21. Asthm? 22. Hy fever /sinus problems? 23. Snoring / sleep pne? 24. Difficult brething / other lung trouble? 25. Tuberculosis? 26. Emphysem? 27. Do you smoke? If <=n number nf prks dy 28. Do you use chewing tobcco? 29. Blood trnsfusion? 30. Blood disorder such s nemi? 31. Bruise esily? 32. Bleeding tendency / bnorml bleed? 33. Heptitis, jundice, or liver disese? 34. Infectious mononucleosis? 35. Gllbldder trouble? 36. Finting spells? 37. Convulsions /epilepsy? NOTES WOMEN ONLY: (UESTIONS Is there possibility of pregnncy? 65. Expected delivery dte? HAVE YOU HAD, OR 00 YOU CURRENTLY HAVE: YES NO 38. Stroke? 39. Thyroid trouble? 40. Dibetes? 41. Low blood sugr? 42. Kidney trouble? 43. High cholesterol? 44. Are you on dilysis? 45. Swollen nkles / rthritis / joint disese? 46. Osteoporosis/ osteopeni? 47. Osteonecrosis? 48. Stomch ulcers / cid reflux? 49. Contgious diseses? 50. Sexully trnsmitted diseses? 51. Problems with immune system? Possibly from mediction / surgery, etc. 52. Dely in heling? 53. A tumor or growth? 54. Cncer/ rdition therpy / chemotherpy? 55. Chronic ftigue / night swets? 56. Are you on diet? 57. A history of lcohol buse? 58. A history of drug buse? 59. Contct lenses? 60. Eye disese /glucom? 61. Mentl helth problems / nxiety / depression? 62. A removble dentl pplince? 63. Pin or clicking of jws when eting? 66. Are you nursing? 67. Are you tking birth control pills? te: Antibiotics (such s penicillin) my lter the effectiveness of birth control pills. Consult your physicin /gynecologist for ssistnce regrding other methods of birth control. NOTES

3 IS THERE A FAMILY HISTORY OF: 68. Cncer? Dibetes?. 70. Hert disese? 71. Anesthesi problems?. ARE YOU NOW TAKING: 72. Any kind of mediction, drug, pills? 73. Blood thinners (Coumdin, Plvix, Aspirin, Vitmin E, Ginko bilob, Aggrenox, Prdx, Fish oil)? 74. Hve you ever tken diet pills? 75. Any nturl product, herbl supplement or homeopthic remedy? 76. Are you tking, or hve you ever tken, bone density meds. or bisphophontes such s Fosmx, Boniv, Actonel, IV- Zomet, or Aredi in the pst 12 yers? YES! NO 77. Trnquilizers, sleeping pills, nti-depressnts, nd/or nrcotics on regulr bsis? If so, plese list: 78. Plese list ny medictions you re currently tking: Mediction Dosge Frequency ARE YOU ALLERGIC TO. OR HAD A REACTION TO: VIS I NO NOTES ^ JU^_^_ 79. Locl nesthetic (numbing meds.)? 80. Penicillin? 81. Other ntibiotics? 82. Sulf drugs? 83. Sodium pentothl / Vlium / other trnquilizers? 84. Aspirin? 85. Amoxicillin? 86. Codeine or other nrcotics? 87. Other medictions? 88. Ltex? 89. Soy? 90. Eggs /yolk? 91. Sulfites? 92. Do you hve ny known llergies? 93. Plese list ny llergies other thn drug llergies: If you re hving surgery tody, hve you hd nything to et or drink in the lst 6 (six) hours? Who is driving you home? Is there ny condition concerning your helth tht the Doctor should be told bout? - If, describe Do you wish to spek to the Dr. privtely bout nything? G Is this visit relted to n ccident? If, wht type of ccident? Automobile Work relted Other Dte of injury Insurnce compny hndling the clim Clim number Nme of ttorney / djuster Telephone number ( ) I certify tht I hve red nd I understnd the questions bove. I cknowledge tht my questions, if ny, bout the inquiries set forth bove hve been nswered to my stisfction. I will not hold my doctor, or ny other member of his / her stff, responsible for ny errors or omissions tht I hve mde in the completion of this form. Signture of ptient (Prent or Gurdin if Minor) Reviewed by Dte FEES & PAYMENTS We mke every effort to keep down the cost of your cre. You cn help by pying upon completion of ech visit. Other rrngements cn be mde with our office mnger depending upon specil circumstnces. An estimte of the chrge for ny procedure or surgery you my require will be given to you upon request. If you hve ny dentl nd/or medicl insurnce we will be gld to fill out the proper forms, but plese complete the identifying informtion on this form. Plese remember tht insurnce is considered method of reimbursing the ptient for fees pid to the doctor nd is not substitute for pyment. Some compnies py fixed llownces for certin procedures nd others py percentge of the chrge. It is your responsibility to py ny deductible mount, co-insurnce or ny other blnce not pid for by your insurnce compny. You will be responsible for ll collection costs, ttorneys fees, nd court costs. Signture of ptient (Prent or Gurdin if Minor) This signture on file is my uthoriztion for the relese of informtion necessry to process my clim. I hereby uthorize pyment to this doctor nmed of the benefits otherwise pyble to me. X _ X Signture of ptient: (Prent or Gurdin if Minor) Dte AUTHORIZATION I uthorize my surgeon nd his / her designted stff, to perform n orl nd mxillofcil exmintion, for the purpose of dignosis nd tretment plnning. Furthermore, I uthorize the tking of ll x-rys required s necessry prt of this exmintion. In ddition, if mediclly necessry, I uthorize the relese of ny informtion cquired in the course of my exmintion nd tretment to my other doctors nd/or insurnce crriers. I permit messges to be left on my phone concerning my ppointment. Dte Signture of ptient (Prent or Gurdin if Minor) Witness Doctor Dte I hereby cknowledge tht copy of this office's tice of Privcy Prctices hs been mde vilble to me. I hve been given the opportunity to sk ny questions I my hve regrding this tice. Signture of ptient (Prent or Gurdin if minor) Dte Copyright 2011 PBHS Inc. To Re-Order Cll (800)

4 Stfford Endodontics 556 Grrisonville Rod, Suite 200 Stfford, VA OFFICE PAYMENT POLICY Ptient: First Nme Initil Lst Nme We re plesed to welcome you to our office. Our prctice hs grown s result of its excellent reltionship with our referring dentists nd ptients. As our ptient, plese feel free to sk ny questions or express ny concerns tht you my hve with Dr. Tolb or Office Mnger. We ccept most forms of pyment however we do not ccept personl checks. We do offer CreCredit s n lternte pyment option. If you need to pply with CreCredit we cn ssist you in this. If you hve insurnce, we will file the clim s courtesy on your behlf nd let the insurnce py us. However, your co-pyment is due prior to tretment. You will lso be responsible for ny portion insurnce does not py for ny reson. We verify insurnce informtion nd benefits however ll clims from your generl dentist my not hve reched processing t the time of our cll. We mke every effort to estimte your co-py nd ensure we mximize your insurnce benefits. INSURANCE: We re preferred providers with most insurnces. Your co-py is due t check-in regrdless of whether you hve both primry nd secondry insurnce crrier. However, if your mximum benefits hve been met for the pln yer, you will be required to py in full. If we re not prticipting provider with your insurnce you re responsible for 100% of our fees. We will file clim with your insurnce crrier nd you will be reimbursed. ATTENTION ALL INSURANCE PATIENTS: The mount of coverge pid by your insurnce compny is bsed on your insurnce compny's "usul nd customry" fee schedule. Their fee schedule is normlly less thn our "ctul" chrges which we hve no control over. Lower pyment is direct result of the pln selected by the subscriber's employer. If we re not preferred providers with your insurnce compny, you re responsible for the remining blnce fter your insurnce hs pid its portion. This is clculted bsed on your mximum benefits vilble nd on the "usul nd customry" fee schedule. In ddition, the ptient or responsible prty (prent or gurdin) is fully responsible for the totl pyment of services performed in this office. This includes ny mounts not covered by helth or dentl insurnce or prepyment progrm tht the ptient or responsible prty my hve. All remining blnces re to be pid in full within 30 dys of tretment dte or, if pplicble, fter your insurnce compny pys. Blnces over thirty (30) dys will be subject to 1.50% monthly interest chrge (minimum chrge of $1.00). If the ccount is turned over for legl collection, the ptient or responsible prty will be lible for ll costs of collection including interest, court costs nd ttorney's fees. If you hve ny questions regrding our office policy plese feel free to spek with the office mnger. By signing below you gree tht you hve red, understnd nd gree to comply with the bove Office Policies. Ptient/Responsible Prty Signture Plese Print Nme Dte Reltionship to Ptient:

5 *PLEASE READ ONLY. Dr. Tolb will go over your cse then signture of consent my be signed. Stfford Endodontics 556 Grrisonville Rod, Suite 200 Stfford, VA Endodontic Tretment Consent nd Informtion Form Wht is Root Cnl? Root cnl therpy is the clening, shping, disinfecting nd filling of the root cnl(s) of the disesed tooth. A treted tooth usully functions normlly s pulpless tooth, not ded tooth. Tretment will usully require one or more ppointments, depending upon the condition of the tooth nd my need dditionl x-rys to be tken throughout the process. Following tretment, the tooth will be brittle nd subject to frcture. A permnent restortion (filling), crown, nd/or post nd core will be necessry to restore the tooth to function. (The fees for these procedures will be dditionl nd these services will be provided by your generl dentist.) The lterntives to endodontic therpy include, no tretment, witing for more definite development of symptoms nd/or tooth extrction. Risks involved in these choices might include pin, infection, swelling, nd tooth loss. PLEASE BE ADVISED OF THE FOLLOWING As rule, 90-95% of routine cses re successful % of redo (retretment) cses re successful. wrrnty or gurntee of success cn be given in root cnl tretment. If the originl tretment is not successful, it my hve to be redone, surgicl procedure my be required or the tooth my need to be removed. Ech of these procedures require dditionl fees to be chrged. Tretment of your cse hs % of success. initil Tretment will be done using Locl Anesthetic Orl Sedtion Nitrous Oxide (dentl gs, conscious sedtion) POSSIBLE UNAVOIDABLE COMPLICATIONS MAY INCLUDE BUT NOT LIMITED TO: 1) Swelling, soreness, infection, trismus (restricted jw opening) or discolortion of the soft or hrd tissue. 2) Brekge of root cnl instruments during tretment, which my be in the judgment of Dr. Tolb to be left in the treted root cnl or require surgery for removl. 3) Frcture of the crown or root of the tooth. 4) Perfortion of the root cnl with instruments, which my require dditionl surgicl corrective tretment or result in premture tooth loss or extrction. 5) Underfill nd/or overfill cnl. 6) Sinus perfortion. 7) Dmge to bridges, existing filling nd crowns. 8) Blocked cnls due to fillings or prior tretment, nturl clcifiction, severely curved roots, nd root resorption. 9) Premture tooth loss due to progressive periodontl (gum) disese. 10) Possible nerve dmge during the dministrtion of nesthesi. There is greter chnce of filure of root cnl therpy if ptient fils to keep scheduled ppointments. Tke pin mediction s directed when you first feel discomfort. Py ttention to ny wrnings on the mediction continer from the phrmcy. If ntibiotics re prescribed, it I VERY IMPORTANT tht you tke ALL of them s directed. I tooth/teeth # hve been dvised by Dr. Tolb tht I require root cnl tretment for my. I understnd tht I m to contct the office for n ppointment six months nd one yer fter tretment is completed so the root cn be evluted. (Included in the tretment fee.) I understnd tht it is my responsibility to set up nd follow through with ll ppointments. Filure to do so my result in the loss of the tooth or dmge to the other teeth nd surrounding bone. I understnd it is criticl to return to my generl dentist to follow-up with n ppointment within 30 dys to complete the permnent restortion of this tooth. I understnd tht if the temporry filling plced by Dr. Tolb comes out before I return to my generl dentist, I m to return to hve the temporry filling replced (t no dditionl cost.) Filure to keep the tooth covered will llow sliv nd food to contminte my tooth nd if this is llowed for more thn couple of dys (less thn week), it will result in my needing to hve this root cnl retreted, which would be t my own expense. All of my questions hve been nswered by Dr. Tolb nd I fully understnd the bove sttements in this consent form. Signture of Ptient/Gurdin Printed Nme Dte Dr. Mostf S. Tolb Dte