Patient Registration

Transcription

1 Patient Registration Last Name First Name Middle Initial Street Address Apt/Unit City, State Zip Home Phone Cell Phone (Text ok? ) Address Primary Number to call first: Birth Date / / Age Sex Marital Status Social Security. - - Occupation Employer Business Address Business Phone Ext Personal Information Referred to us by In case of emergency, please contact: Name Home Phone Address City/State Relationship Dental Insurance Information (if applicable) Primary Carrier: Secondary Carrier: Ins. Co Employee Name Employer Group Ins. ID # Employee Social - - Employee Birth date / / Ins. Co Employee Name Employer Group Ins. ID # Employee Social - - Employee Birth date / / Account Information Person financially responsible for account: Self Spouse Other If other than self, please complete the following information: Name Relation to Patient Occupation Employer Business Address Business Phone Ext Patient/Guardian Signature Date

2 Medical History Information Guest Name: Date of Birth: Have you been under the care of a medical doctor during the past two years? Physician s Name Address Phone Have you been a patient at the hospital during the past two years? Have you taken any medication or drugs during the past two years? Are you now taking any medication, drugs or pills, including aspirin? If yes, please list: Are you aware of being allergic to or have you ever reacted adversely to any medication or substance? If yes, please list: Are you having pain or discomfort at this time? Have you ever received intravenous (IV) bisphosphonates such as Zometa (Zoledronate) or Pamidronate (Aredia)? Have you ever taken oral bisphosphonates such as Fosamax, Actonel or Boniva? Indicate which of the following you have had or have at present. Circle yes or no next to each item. Heart Failure Stroke Have you seen a Acupuncturist? Heart Disease or Attack Artificial Joints Have you seen a Chiropractor? Angina Pectoris Kidney Trouble Have you seen a Neurologist? Congenital Heart Disease Ulcers Have you seen an ENT? Heart Murmur Diabetes Bite feels off High Blood Pressure Thyroid Problems Neck/Back Pain Arteriosclerosis Glaucoma Have you taken Prednisone? Mitral Valve Prolapse Cosmetic Surgery Temporal Arteritis Artificial Heart Valve Emphysema Facial Muscle Pain Heart Pacemaker Tuberculosis Over closed mouth Heart Surgery Asthma Ringing in ears Rheumatic Fever Allergies or Hives Fainting or Dizzy Spells Arthritis Epilepsy or Seizures Nervousness Rheumatoid Arthritis Radiation Therapy History of Depression Yellow Jaundice Chemotherapy Headaches/ Migraines Cortisone Medicine Hepatitis A (infectious) Jaw Popping Drug Addiction Hepatitis B (serum) Limited Opening Smoker Hist. of Cancer/Tumor Sinus Trouble Liver Disease Bruise Easily Pain in Jaw Joints Sickle Cell Disease Hemophilia Obstructive Sleep Disorder Anemia Blood Transfusion Insomnia A.I.D.S./ H.I.V. Positive Venereal Disease Sleep Apnea Snoring Do you have or ever had any disease, condition, or problem not listed? (If yes please list separately) Do you use more than two pillows to sleep? Do you ever wake up from sleep and feel short of breath? Do your ankles swell during the day? If you walk up stairs or take a walk, do you ever have to stop because of pain in your chest, shortness of breath, or because you are very tired? Are you on a special diet? Have you lost or gained more than 10 pounds in the past year? Women Only: Are you pregnant?, What month due? Are you nursing? Are you taking birth control pills? I find the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions all questions truthfully and to the best of my knowledge. Consent for examination (only) The undersigned hereby authorizes Doctor to take X-rays, study models, photos, or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient s dental needs. I understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for all services provided in this office for me or my dependents is mine, due and payable at the time services are rendered unless written and signed financial arrangement has been made. I further understand that any insurance reimbursement is my responsibility and that a 1 ½% finance charge (18% annually) will be added to any balance over 60 days. In the event of default, I (We) agree to pay legal interest on the indebtedness, together with such collection costs (no less than $50) and reasonable attorney fees as may be required to effect collection of this note. Print Name Sign Date Witness

3 Dental History Date Guest Name Preferred Name Date of Birth Work/ Retired from Hobbies What if any problems are you having right now? Sensitivity: / Hot Cold Bite Sweets Other When was your last dental visit? What was done? How would you rate the health of your teeth and gums on a scale of 1 to 10? Are you able to eat everything you want? / What is most important to you about your teeth? How would you rate how happy you are with your smile on a scale of 1 to 10? Are you ever self-conscious about your smile? / What about your teeth/smile is not as nice as you would like it to be? If you could have your mouth any way you want it, what would it be like? Do you have any concerns about your old metal / mercury fillings? / Have you been told you have gum disease or pyorrhea? / What kind of gum treatment have you had in the past? How do you take care of your teeth? Manual Brush Electric Brush Floss Irrigator Tongue Cleaner Rinse Do you have bleeding when you brush or floss? / Does food get caught between your teeth? / Do your jaws ever: Pop ise Pain Lock Open Lock Close ne Are you aware of clenching during the day or grinding at night? / Have you ever been told you grind your teeth at night? / Do you have a bite guard? / Use it when? Have you ever had sedation for your dental treatment? / Is there anything else we could do or not do to make your visits absolutely perfect? _ Is there anything that would prevent you from having treatment now? _ Would longer appointments work better for you if it meant fewer visits? / Have you given any thought as to a lifetime budget for your dentistry? _

4 HIPAA Acknowledgement ACKNOWLEDGEMENT OF RECEIPT OF OUR ADHERENCE TO STATE AND FEDERAL PATIENT PRIVACY PRACTICES Please be advised that THE SMILE CENTRE will only use your personal & health information that is retained in your patient chart for professional, (doctor-to-doctor type) communications. We will file insurance information electronically and/or via U.S. mail within the same privacy guidelines. Do we have your permission to: Send appointment reminders to your home/ Leave the following information on your home or cell answering machine/ voice mail: Appointment Information Billing Information Leave the following information on your work answering machine/ voic Appointment Information Billing Information I give permission to share appointment information with the person named below: Name: I give permission to share billing information with the person named below: Name: The undersigned acknowledges receipt of the current tice of Privacy Practices at The Smile Centre, P.A. Date: Please Sign Name: Please Print Name: Thank you. If you have any questions about this form or about our complete Privacy Policy, please contact our privacy policy officer, Tricia Stanley, Administrator. Signature of Smile Centre Representative:

5 Model Release Guest Name: DOB: For consideration received, receipt whereof is acknowledged, I, the undersigned, hereby give The Smile Centre, P.A. and its doctors and team the absolute right and permission to copyright and/or publish, or use pictures, film or photographic portraits of me, or those in which I may be included in whole or in part, or composite in form or character, in conjunction with my own or a fictitious name, or reproductions thereof in color or otherwise, made through any media, for art, advertising, trade or any other lawful purpose, as agreed to by the above named parties. Furthermore, I hereby waive any right to inspect and/or approve the finished product or the copy that may be used in connection therewith, or the use to which it may be applied. I hereby release, discharge, and agree to save The Smile Centre, P.A. and Dr. Richard A. Stanley, its doctors and team from any liability for any blurring, distortion, optical illusion, alteration, or use in composite form, whether intentional or otherwise, that may occur or be produced in the taking of said pictures, or in any processing tending towards the completion of the finished product. Guest Signature The Smile Centre Representative Date Date