COSMETIC DENTISTRY CEREC IMPLANTS IV SEDATION

Transcription

1 COSMETIC DENTISTRY CEREC IMPLANTS IV SEDATION WELCOME TO BELMAR PARK DENTAL CARE. WE SINCERELY APPRECIATE YOU CHOOSING OUR OFFICE FOR YOUR DENTAL AND ORAL HEALTH CARE NEEDS. PLEASE BE ASSURED THAT WE WILL WORK HARD TO CONTINUALLY EARN THE TRUST THAT YOU HAVE PLACED IN US. IN ORDER FOR US TO SERVE YOU BETTER, PLEASE TAKE SOME TIME TO COMPLETE THIS INFORMATION FORM AS THOROUGHLY AS POSSIBLE. PATIENT INFORMATION Patient s Name Address City State Zip Address Employer Name Employer Address City State Zip Who may we thank for referring you to us for care? Where would you like to be contacted? Spouse Name Spouse Employer Address City State Zip If the Patient is a minor, please tell us about the parent or guardian Your Name Your Address City State Zip Home Phone Cell Phone Date of Birth Sex M F Social Security # Business Phone Your Position Date of Birth Social Security # Spouse Cell Phone Business Phone Relationship to Patient Your Home Phone # Your Social Security # Name and phone of emergency contact not living with you Do you have Dental Insurance? Yes No INSURANCE INFORMATION Name of Insured Person Social Security # of Insured Insurance Company Address Phone Insured Date of Birth Group No. Effective Date Plan Name or Number I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance company. Our policy requires payment in full for all services rendered at the time of each visit. If account is not paid within 90 days of the date of service and no financial arrangements have been made, a finance charge at a periodic rate of 1.5% per month will be added to your account. You will be responsible for legal, and collection agency fees, interest charges and any other expenses incurred in collecting of your account. After your second missed appointment in any twelve month period, we reserve the right to charge a missed appointment fee. This fee is not covered under insurance and will be your responsibility. In order to avoid this charge any necessary cancellations must be made at least 48 hours in advance. Thank you for understanding our policies. Please let us know if you have any questions or concerns. Patient s (Guardian s) Signature Date

2 MEDICAL HISTORY UPDATE Your Name Today s Date Physician s Name Phone # Are you under a doctor s care now? Why? YES NO Have you been hospitalized during the past two years? Why? YES NO Are you taking any medications, pills, or drugs? What? YES NO Please list any allergies to drugs, medications, anesthetics or latex Please tell us if you have had any of the following by checking the appropriate box Bacterial Endocarditis Heart Murmur Irregular Heart Beat High Blood Pressure Low Blood Pressure Rheumatic Heart Fever Rheumatic Heart Disease Artificial Heart Valves Congenital Heart Lesion Heart Attack year Angina/Chest Pain Heart Pacemaker year Heart Surgery year Congestive Heart Failure Stomach Problems/Reflux Hemophelia Blood Disease Sickle Cell Anemia Anemia/Blood Problems Excessive Bleeding Asthma Respiratory Disease Shortness of Breath Hay Fever Sinus Problems Tuberculosis Eye Disorders/Glaucoma AIDS/HIV Immunosupressive Disorders/ARC Any Artificial Replacement Artifical Knee, Hip, Joint, Pins, Plate year Rheumatism/Arthritis Neurological Problems Epilepsy/Seizures Psychiatric Problems Emotional Problems Alcoholism Chemical Dependency Drug Addiction Tobacco Use Malignancies Cancers, Tumors, Growths Radiation Treatments Diabetes Kidney Problems Dialysis Liver Problems Hepatitis Stroke Thyroid Problems Ulcer/Colitis Venereal Disease Herpes Fever Blisters Latex Allergy Pregnant months Planning to be pregnant soon Oral Contraceptives Have you ever taken medication for osteoporosis or to improve bone density? YES NO Please list any other MEDICAL CONDITIONS not mentioned above DENTAL HISTORY How long since your last dental visit? What was done at this time? Previous dentist s name Phone # YES NO NA Have you made regular dental visits? Were dental x-rays taken recently? Do you have a current pano or full mouth series? Have you lost any teeth or have any teeth been removed? Would you like to know about permanent replacements? Have you ever had any problems or complications with previous dental treatment? Do you clench or grind your teeth? Does your jaw click or pop? Have you experienced any pain or soreness in the muscles of your face or around your ear? Do you have frequent headaches, neckache or shoulder aches? Does food get caught in your teeth? Are any of your teeth sensitive to Hot, Cold, Sweets, and or pressure? YES NO NA Have your wisdom teeth been removed Do your gums bleed or hurt? How often do you brush your teeth? 1x 2x s 3x s a day Do you use dental floss? Are any of your teeth loose, tipped, shifted or chipped? Are you unhappy with the appearance of your teeth? Do you feel your breath is offensive at times? Have you ever had gum treatment or surgery? Have you had any orthodontic work? How do you feel about your teeth in general? Have you had any unpleasant dental experiences or is there anything about dentistry that you strongly dislike? Do you have any questions or concerns? Patient s (Guardian s) Signature Date

3 Patient Sleep Screening Form Patient Name (PRINT) Section 1: Epworth Sleepiness Scale Please indicate how likely you are to doze off or fall asleep in the following situations: (0=never, 1=slight, 2=moderate, 3=high chance of dozing) CIRCLE ONE RESPONSE FOR EACH QUESTION Sitting and reading Watching television Sitting in a public place As a passenger in a car for one hour Sitting & talking to someone Sitting down quietly after lunch without alcohol Lying down to rest in the afternoon Section 2: Patient Evaluation Fill in the blanks, circle one yes or no response for each question Neck Circumference Is it >17 (Men) or >15 (Women)? 0 1 Have you gained at least 15lbs in the past 6 months? 0 1 Section 3 Subjective Sleep Evaluation Please circle one yes or no response for each question Do you snore? Do you feel that in some way your sleep is not refreshing or restful? Do you wake up at night or in the mornings with headaches? Do you have trouble remembering things or paying attention during the day? Do you have high blood pressure? Section 4: Prior Diagnosis Have you previously been diagnosed with sleep apnea? 0 1 If Yes: When were you diagnosed? (Approx mo/yr) Were you put on CPAP Therapy for treatment? Are you still using your CPAP every night? Notes: (Please insert any notes for the doctor regarding snoring, sleep patterns or sleep apnea that you feel may be appropriate. Use back of page if necessary.) Patient Signature: Date: Advanced screening criteria, if yes to any below pt should be scheduled for advanced OSA screening.

4 IMPLANTS IV SEDATION COSMETIC DENTISTRY CEREC WELCOME TO BELMAR PARK DENTAL CARE. WE SINCERELY APPRECIATE YOU CHOOSING OUR OFFICE FOR YOUR DENTAL AND ORAL HEALTH CARE NEEDS. PLEASE BE ASSURED THAT WE WILL WORK HARD TO CONTINUALLY EARN THE TRUST THAT YOU HAVE PLACED IN US. IN ORDER FOR US TO SERVE YOU BETTER, PLEASE TAKE SOME TIME TO COMPLETE THIS INFORMATION FORM AS THOROUGHLY AS POSSIBLE. TELL US WHAT YOU THINK ABOUT YOUR SMILE Before we visit with you for a comprehensive consultation, we want to understand your thoughts and concerns. We know you value your time, so we developed this quick questionnaire as a way to put your ideas down on paper and as a way for us to begin to understand what you need or want for your smile. Would you like to make improvements to your smile? Yes No Tell us the changes you would like to see... STRAIGHTER TEETH WITHOUT CONVENTIONAL BRACES This can be accomplished with Invisalign clear retainers, veneers, bonding or contouring. BRIGHTER/WHITER TEETH We have a variety of customized professional whitening treatments, including immediate zoom whitening treatments in our office or custom trays for at home whitening. BETTER SHAPED TEETH Porcelain veneers are a great way to make a dramatic change to the color, shape, or even position of your teeth. You will have a fuller, natural and nearly perfect smile. ELIMINATE THE SPACES BETWEEN MY TEETH Orthodontics, veneers and crowns are all great options for getting rid of spaces between your teeth. REPLACE MISSING TEETH...GET RID OF REMOVABLE PARTIALS OR DENTURES Implants provide a solid permanent structure for replacement teeth and make possible all the things you used to be able to do with your natural teeth. REPLACE CROWNS WITHOUT THE HASSLE OF MULTIPLE VISITS In a matter of an hour or two we can replace your old silver or gold crowns and silver fillings with natural-looking porcelain. Our new CEREC CAD/CAM computer technology manufactures beautiful porcelain crowns in our office while you wait...no more need for temporary crowns and multiple appointments. TAKE THE FEAR OUT OF DENTISTRY We offer IV sedation DENTISTRY which allows you to relax... you re unaware of the time passing by, yet able to communicate with us during your treatment. SHOW LESS GUMS WHEN I SMILE Tissue re-contouring is simple and really enhances your smile. MAKE ALL MY TEETH THE SAME SHADE & EVEN WHITER A variety of restorative dental technologies and teeth whitening can accomplish this for you. STOP MY TEETH FROM CHIPPING AND WEARING A custom-made night guard can protect your teeth from grinding and fractures. MODEL RELEASE I give permission to Belmar Park Dental Care/David G. Collins, DDS and Associates to use my name and photographic likeness in all forms and media for marketing, educational, and any other lawful purposes. Print Name Signature Date If Model is under 18 I,, am the parent/legal guardian of the individual named above. I have read this release and approve of its terms. Print Name Signature Date

5 No Show and Cancellation Policy We appreciate that you have chosen Belmar Park Dental Care as your dental providers. We are dedicated to providing the best possible care for you, from the time you enter the waiting room until you check out. We value your time and know that it is very important. Since we try to accommodate all patients to the best of our ability we want to share our no show, re-schedule, and cancellation policy with you. As a patient it is your responsibility to contact Belmar Park Dental Care in a timely manner to cancel or re-schedule an appointment. At times the doctors schedules can get booked out quickly, and without proper notice we are not able to work those patients in that may need a sooner appointment. If you fail to cancel or re-schedule within 24 hours before your appointment, or don t show up for your appointment a fee will be charged to your account. Patient Name Printed: Patient Signature: Date

6 Belmar Park Dental Care Notice of Privacy Practices This notice describes how your health information may be used and disclosed and how you can access this information. Please review it carefully. At Belmar Park Dental Care, we have always kept your health information secure and confidential. A new law requires us to continue maintaining your privacy, to give you this notice and to follow the terms of this notice. The law permits us to use or disclose your health information to those involved in your treatment. For example, a review of your file by a specialist doctor whom we may involve in your care. We may use or disclose your health information for payment of your services. For example, we may send a report of your progress to your insurance company. We may use or disclose your health information for our normal healthcare operations. For example, one of our staff will enter your information into our computer. We may share your medical information with our business associates, such as a billing service. We have a written contract with each business associate that requires them to protect your privacy. We may use your information to contact you. For example, we may send newsletters or other information. We may also want to call and remind you about your appointments. If you are not home, we may leave this information on your answering machine or with the person who answers the telephone. In an emergency, we may disclose your health information to a family member or another person responsible for your care. We may release some or all of your health information when required by law. If this practice is sold, your information will become the property of the new owner. Except as described above, this practice will not use or disclose your health information without your prior written authorization. You may request in writing that we not use or disclose your health information as described above. We will let you know if we can fulfill your request. You have the right to know of any uses or disclosures we make with your health information beyond the above normal uses. As we will need to contact you from time to time, we will use whatever address or telephone number you prefer. You have the right to transfer copies of your health information to another practice. We will mail your files for you. You have the right see and receive a copy of your health information, with a few exceptions. Give us a written request regarding the information you want to see. If you also want a copy of your records, we may charge you a reasonable fee for the copies. You have the right to request an amendment or change to your health information. Give us your request to make changes in writing. If you wish to include a statement in your file, please give it to us in writing. We may or may not make the changes you request, but will be happy to include your statement in your file. If we agree to an amendment or change, we will not remove nor alter earlier documents, but will add new information. You have the right to receive a copy of this notice. If we change any of the details of this notice, we will notify you of the changes in writing. You may file a complaint with the Department of Health and Human Services, 200 Independence Avenue, S.W., Room 509F, Washington, DC You will not be retaliated against for filing a complaint. However, before filing a complaint, or for more information or assistance regarding your health information privacy, please contact our Privacy Officer, Karen Galarza, at (303) This notice went into effect as of April 14, Acknowledgement I have received a copy of The Belmar Park Dental Care Notice of Privacy Practices. Signed Print Name If signing as a parent or guardian, please note the name of the patient