PATIENT INFORMATION PATIENT NAME FIRST MIDDLE LAST HOW YOU WOULD LIKE TO BE ADDRESSED? HOME ADDRESS TEXT REMINDERS DATE OF BIRTH YES NO SOCIAL SECURITY # PHONE HOME EMPLOYER/OCCUPATION EMERGENCY CONTACT BUSINESS MARITAL STATUS SINGLE MARRIED DIVORCED WIDOWED MOBILE GENDER MALE FEMALE FIRST LAST PHONE RELATION TO PATIENT WITH WHOM ARE WE ALLOWED TO SPEAK ABOUT YOUR DENTAL HEALTH (IN ADDITION TO PARENT, GUARDIAN, INSURANCE) ARE ANY FAMILY MEMBERS PATIENTS WITH US? WHO? WHOM MAY WE THANK FOR REFERRING YOU? BILLING INFORMATION PERSON RESPONSIBLE FOR ACCOUNT FIRST LAST PHONE RELATION TO PATIENT ADDRESS DATE OF BIRTH SOCIAL SECURITY # EMPLOYER NAME EMPLOYER ADDRESS INSURANCE INFORMATION We provide the courtesy of filing insurance claims on your behalf. Please provide your insurance ID card at the time of registration. POLICY HOLDER PATIENT RESPONSIBLE PARTY DENTAL INSURANCE COMPANY PHONE ADDRESS INSURANCE PLAN NAME INSURANCE ID NUMBER GROUP ID UNION OR LOCAL NAME - Page 1 of 9 -
MEDICAL HISTORY NAME OF PERSON COMPLETING FORM RELATION TO PATIENT PHYSICIAN NAME PHYSICIAN PHONE OTHER PHYSICIANS APPROXIMATE DATE OF LAST PHYSICAL HEIGHT WEIGHT LIST ANY CONDITIONS OR ILLNESS FOR WHICH YOU ARE BEING TREATED: DESCRIBE ANY TREATMENT RECIEVED IN A HOSPITAL OR EMERGENCY ROOM WITHIN THE LAST TWO YEARS: LIST ANY PREVIOUS SURGERIES WITH APPROXIMATE DATES (e.g. Back surgery, gall bladder, tonsillectory, prosthetic joint replacement) DESCRIBE ANY CURRENT CONDITIONS THAT CAN BE SPREAD BY COUGHING: FOR WOMEN ARE YOU PREGNANT (OR THINK YOU MAY BE)? YES NO ARE YOU TAKING BIRTH CONTROL PILLS? YES NO ARE YOU NURSING? YES NO INDICATE ANY ALLERGIES TO THE FOLLOWING: ASPIRIN PENICILLIN LATEX IODINE DYE CODEINE SULFA DENTAL RESTORATIVE MATERIALS PLEASE LIST ANY OTHER ALLERGIES CHECK IF YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING: AIDS/HIV POSITIVE ANEMIA ARTHRITIS, RHEUMATISM ARTIFICIAL HEART VALVE ARTIFICIAL JOINTS ASTHMA AUTOIMMUNE DISEASE BACK PROBLEMS BISPHOSPHONATE BLOOD DISEASE CANCER CHEMICAL DEPENDENCY CHEMO/RADIATION THERAPY CIRCULATORY PROBLEMS CORTISONE TREATMENTS COUGH, PERSISTENT COUGH UP BLOOD DIABETES EPILEPSY FAINTING GASTROINTESTINAL DISORDER GLAUCOMA HEADACHES HEART MURMUR HEART PROBLEMS, DESCRIBE HEMOPHILIA HEPATITIS A/ B /OTHER HIGH BLOOD PRESSURE JAW PAIN KIDNEY DISEASE LIVER DISEASE MITRAL VALVE PROLAPSE NERVOUS PROBLEMS PACEMAKER PSYCHIATRIC CARE RADIATION TREATMENT RESPIRATORY DISEASE RHEUMATIC FEVER SCARLET FEVER SHORTNESS OF BREATH SKIN RASH SLEEP APNEA STROKE SWELLING OF FEET/ANKLES THYROID PROBLEMS TOBACCO HABIT TUBERCULOSIS ULCER VENEREAL DISEASE DESCRIBE ANY OTHER MEDICAL CONDITIONS WE SHOULD BE AWARE OF: - Page 2 of 9 -
MEDICAL HISTORY (CONT.) PREFERRED PHARMACY PHARMACY PHONE ADDRESS DO YOU TAKE ANY OF THESE ANTICOAGULANTS? ASPIRIN PLAVIX ELIQUIS XARELTO PRADAXA DO YOU TAKE COUMADIN (BLOOD THINNER)? YES NO DO YOU TAKE STEROID MEDICATION? YES NO DO YOU TAKE DRUGS TO SUPPRESS THE IMMUNE SYSTEM? YES NO HAVE YOU EVER TAKEN BIPHOSPHONATES FOR OSTEOPOROSIS OR FOR CHEMOTHERAPY YES NO TO TREAT MULTIPLE MYELOMA? OTHER OVER THE COUNTER AND PRESCRIPTION DRUGS CURRENT VITAMINS, HERBALS, OR OTHER REMEDIES DO YOU CONSUME ALCOHOL? NONE SOCIAL USE MORE THAN SOCIAL USE DO YOU USE TOBACCO PRODUCTS? NONE CIGARETTE CIGAR PIPE SMOKELSS DO YOU USE STREET DRUGS? NONE MARIJUANA COCAINE METHAMPHETAMINE HEROINE OTHER HEALTH RISK ASSESSMENT DO YOU HAVE DIFFICULTY CONCENTRATING OR STAYING AWAKE DURING THE DAY? NO YES DO YOU HAVE OR ARE BEING TREATED FOR HIGH BLOOD PRESSURE? NO YES DO YOU SNORE LOUDLY? NO YES DO YOU WEAR A C-PAP OR SLEEP APPLIANCE? NO YES ARE YOUR TONSILS PRESENT? NO YES DESCRIBE YOUR SLEEP POSITION: SIDE FRONT BACK To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have a change in my health, I will inform my doctor at the next appointment. Print Name Signature of Patient, Parent, or Guardian Date - Page 3 of 9 -
DENTAL HISTORY HOW CAN WE HELP YOU TODAY? DO YOU HAVE ANY TOOTH OR ORAL PAIN? YES NO IF YES, WHERE IS THE PAIN? ARE YOU TAKING PAIN MEDICATION FOR ORAL PAIN? YES NO IF YES, WHAT MEDICATION? ARE YOU TAKING ANTIBIOTICS FOR ORAL INFECTION? YES NO IF YES, WHICH ANTIBIOTIC? CHECK IF YOU HAVE OR HAVE HAD ANY OF THE FOLLOWING: BAD BREATH BITE PROBLEMS BROKEN FILLINGS BROKEN TEETH CAVITY PROBLEMS CHEWING PROBLEMS GUM PROBLEMS MISSING TEETH SMILE/COSMETIC ISSUES OLD FILLINGS WHICH SHOULD BE EVALUATED ORAL CARE HABITS WHEN WAS YOUR LAST DENTAL VISIT? WHAT WAS DONE AT THAT VISIT? CLEANING FILLING/CROWN/BRIDGE DENTURE/PARTIAL EVALUATION EXTRACTION GUM TREATMENT ROOT CANAL UNCERTAIN WHEN WERE YOUR LAST DENTAL X-RAYS TAKEN? HOW OFTEN DO YOU SEE A DENTIST FOR ROUTINE CARE? ANNUALLY ONLY FOR PAIN TWICE A YEAR SELDOM 3 OR 4 TIMES A YEAR NEVER HOW MANY CAVITIES HAVE YOU HAD RECENTLY? NONE 2 OR LESS IN PAST THREE YEARS THREE OR MORE DURING THE LAST THREE YEARS UNCERTAIN HAVE YOU LOST ANY TEETH BESIDES YOUR BABY TEETH? NO YES IF APPLICABLE, CHECK THE REASON FOR LOSS: WISDOM TEETH EXTRACTED EXTRACTED DUE TO DECAY EXTRACTED DUE TO GUM PROBLEM FOR ORTHODONTIC CARE DUE TO AN ACCIDENT REASON NOT LISTED HOW IS YOUR FAMILY S DENTAL HEALTH? MOST HAVE GOOD TEETH MOST HAVE BAD TEETH HISTORY OF DENTURES HISTORY OF TOOTH LOSS HISTORY OF GUM UNCERTAIN DISEASE - Page 4 of 9 -
DENTAL HISTORY (CONT.) WHAT ARE YOUR BRUSHING HABITS? ONCE PER DAY TWICE PER DAY THREE TIMES PER DAY SELDOM NEVER NOT APPLICABLE WHAT TYPE OF TOOTHBRUSH DO YOU USE? HARD MEDIUM SOFT SONICARE ELECTRIC/ROTARY UNCERTAIN NOT APPLICABLE HOW MANY TIMES A DAY DO YOU EAT OR DRINK ITEMS CONTAINING SUGAR? LESS THAN 3 TIMES MORE THAN 3 TIMES MORE THAN 5 TIMES NONE IS THE WATER AT YOUR HOME FLUORIDATED? YES NO UNCERTAIN DO YOU FLOSS YOUR TEETH? DAILY WEEKLY OCCASIONALLY SELDOM NEVER NOT APPLICABLE DO YOU USE OTHER ORAL CLEANING PRODUCTS? WATERPIK MOUTH RINSE TOOTHPICK NOT APPLICABLE DOES YOUR MOUTH FEEL DRY MOST OF THE TIME? NO YES NOT APPLICABLE IF SO, IS YOUR DRY MOUTH A NEW EXPERIENCE? NO YES NOT APPLICABLE WHAT IS THE SEVERITY OF YOUR DRY MOUTH? MILD MODERATE SEVERE HAVE YOU EXPERIENCED ANY ALTERATION IN YOUR TASTE PERCEPTION? NO YES ARE THERE PHYSICAL OR MENTAL LIMITATIONS PREVENTING ORAL HYGIENE? NO YES PERIODONTAL (GUM) HEALTH ARE THERE PHYSICAL OR MENTAL LIMITATIONS PREVENTING ORAL HYGIENE? NO YES DOES FOOD GET STUCK BETWEEN YOUR TEETH? NO YES, A FEW PLACES YES, IN MANY PLACES NOT APPLICABLE DO YOUR GUMS EVER BLEED WHEN BRUSHING YOUR TEETH? NO OCCASIONALLY YES NOT APPLICABLE ARE ANY OF YOUR TEETH LOOSE? NO YES IF YES, WHERE? ARE YOU CONCERNED ABOUT RECEDING GUMS? NO YES IF YES, WHERE? CHEWING ABILITY CAN YOU CHEW YOUR FOOD WELL? YES NO NOT WELL NOT APPLICABLE CAN YOU CHEW HARD FOOD COMFORTABLY? YES NO DO YOU HAVE PARTIALS OR DENTURES? NO YES IF YOU DO, DO THEY WORK WELL? YES NO NOT WELL ARE YOUR TEETH VERY SENSITIVE TO HOT OR COLD? NO YES SOMETIMES NOT APPLICABLE DO YOU HAVE ANY ACHES OR PAINS IN YOUR JAWS OR EARS? NO YES DO YOU HAVE ANY JAW CLICKING OR POPPING? NO YES ARE YOU AWARE OF ANY HABITS OF GRINDING OR CLENCHING? NO YES ARE YOU INTERESTED IN REPLACING LOST TEETH? NO YES UNCERTAIN SMILE DO YOU LIKE YOUR SMILE? YES NO WOULD LIKE WHITER TEETH WOULD LIKE TO DISCUSS SMILE UNCERTAIN - Page 5 of 9 -
DENTAL HISTORY (CONT.) PAST DENTAL CARE DO YOU LIKE YOUR SMILE? YES NO WOULD LIKE WHITER TEETH WOULD LIKE TO DISCUSS SMILE UNCERTAIN HAVE YOU EVER HAD TROUBLE WITH A PREVIOUS DENTAL TREATMENT? PREVIOUS DENTIST: NO YES IF YES, PLEASE DESCRIBE: CITY: STATE: PHONE: WHY ARE YOU CHANGING? HAVE YOU EVER HAD ROOT CANAL TREATMENT? NO YES UNCERTAIN HAVE YOU EVER HAD PERIODONTAL (GUM) TREATMENT? NO YES UNCERTAIN HAVE YOU EVER HAD BRACES? NO YES UNCERTAIN HAVE YOU EVER HAD YOUR TEETH GROUND OR YOUR BITE ADJUSTED? NO YES UNCERTAIN BREATH ODOR DO YOU HAVE A PROBLEM WITH BAD BREATH ODOR? NO YES DENTAL CARE ANXIETY PLEASE CHECK ANY OF THE FOLLWING THAT DESCRIBE YOU: DENTAL CARE DOES NOT FRIGHTEN ME I AM FRIGHTENED OF DENTAL CARE I HAVE EXTREME DENTAL PHOBIA LOCAL ANESTHESIA WORKS WELL FOR ME A RELAXATION PILL HELPS ME WITH DENTAL CARE NITROUS OXIDE (LAUGHING GAS) HELPS ME TOLERATE DENTAL CARE I REQUIRE IV SEDATION OR GENERAL ANESTHESIA OTHER MATTERS YOU WOULD LIKE TO TELL US ABOUT DO YOU HAVE OTHER PROBLEMS YOU WOULD LIKE TO TELL US ABOUT WHICH HAVE NOT BEEN IDENTIFIED? - Page 6 of 9 -
CONSENT FOR SERVICES 1. I hereby authorize the doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis. Initial: 2. Upon such diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. Initial: 3. I agree to the use of anesthetics, sedatives, and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital on any possible complication. Initial: 4. I agree to be responsible for payment of all services on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. Initial: 5. I hereby give the doctor the absolute right and permission to use my photograph/slides for education or promotional purposes. The undersigned completely and forever releases any right to present or future compensation in connection with the use of said photographs/slides. Initial: 6. I acknowledge that I reviewed Loyalsock Dental Associates HIPAA and Notice of Privacy Practices. A copy is available upon request. Initial: Signature of Patient, Parent, or Guardian Date Relationship to Patient - Page 7 of 9 -
PATIENT PRIVACY RELEASE FORM I consent to disclosure of the following protected health information about me to the following family members, medical or dental providers (involved in my dental care such as referring doctors), or persons (insurance companies) involved in my care or payment of my care for the following that may apply: All dental/medical information Information necessary to schedule appointments for me Lab results/radiographs Information necessary to provide for calling in or picking up prescriptions Information necessary to my family members, persons, and dental/medical providers Information necessary to bill for or submit claims for care provided for me by my dental insurance or FSA accounts I authorize this Health Provider and/or staff to leave medical or account information pertaining to my care by the following methods and will assume responsibility to notify them whenever this information changes: Home/Cell Telephone Yes No Work Telephone Yes No Please list names of authorized persons: Rights of the patient I understand I have the right to revoke this authorization at any time and that I have the right to inspect or copy the protected health information to be disclose in this document by sending written authorization to Joyce Kim, DDS. I understand that I have the right to refuse to sign this authorization and that any treatment will not be conditioned on sighing this authorization. This authorization shall be effective until revoked by the patient or representative signing the authorization. Signature of Patient/Parent/Guardian Date - Page 8 of 9 -
RECORDS RELEASE FORM I,, authorize Loyalsock Dental Associates to request the following records from my previous dentist. Previous Dentist: Name: Address: City: Phone: Fax: Please note that Loyalsock Dental Associates is requesting the following records: 1. All x-rays from the last five years 2. All perio readings 3. Recommended treatment and treatment plans Signature Date Note to patients: Please send this form back either by fax to: 570-323-5850 or scan and email to loyalsockdental@gmail.com before your appointment. Note to doctor: Loyalsock Dental Associates is a chartless office and would prefer that the above records be sent via email to the loyalsockdental@gmail.com. Records may also be sent to: Loyalsock Dental Associates 1501 Washington Blvd. Williamsport, PA 17701 - Page 9 of 9 -