Patient Information Full Name Preferred Name Home Address City, St, Zip Home Phone # E-Mail Address Employed By Work Phone # Occupation Pager/Cell Phone # Male Female Birth Social Security # Married Single Divorced Widowed List all family members cared for in our office: Whom may we thank for referring you? Spouse or Responsible Party Information Full Name Home Address Home Phone # E-Mail Address Relationship City, St, Zip Insurance Information Full Name Relationship Birth Social Security # Employer Insurance Co. Name Group # Insurance Co. Address Insurance Co. Ph# I UNDERSTAND AND AGREE THAT, REGARDLESS OF MY INSURANCE STATUS, I AM ULTIMATELY RESPONSIBLE FOR THE BALANCE ON MY ACCOUNT FOR ANY PROFESSIONAL SERVICES.
PATIENT MEDICAL HISTORY Patient Name Although dental personnel primarily treatthe area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician s care now? Yes No Doctor s Name Address Have you ever been told to take antibiotics prior to dental treatment? Yes No Have you ever had a serious head of neck injury? Yes No Are you taking any medications, pills, or drugs? Yes No Medications Taking: Reasons For Taking: Do you use tobacco? Yes No Do you use controlled substances? Yes No Do you carry any emergencey medications? Yes No If so, where is it? WOMEN: Are you - Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives? Are you allergic to any of the following? Aspirin Penicillin Codeine Acrylic Metal Latex Local anesthetics Other (specify) Do you have, or have you had, any of the following? AIDS/HIV Positive Alzheimer's Disease Anemia Angina Arthritis/Gout Artificial Heart Valve* Artificial Joint' Asthma Blood Disease Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Glaucoma Hay Fever Heart Attack/Failure Heart Murmur* Heart Pace Maker* Heart Trouble/Disease Heart Valve Replacement Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Have you ever had any serious illness not listed above? Yes No Comments Liver Disease Low Blood Pressure Lung Disease Lupus Mitral Valve Prolapse* Organ Transplant Pain in Jaw Joints Parathyroid Disease Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever* Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice Sjogren Syndrome *Condition may require medication Last dental exam? X-rays? To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
O F F I C E P O L I C Y Ensuring our patients receive the highest quality care possible is the goal of our practice. Payment is due at the time services are rendered. We accept cash, check, major credit cards and file insurance on assignment. We have financing available through Care Credit. This allows you to start treatment today and spread payment over time. Care Credit is subject to credit approval,if credit application is declined, another form of payment listed above is required. Returned check fee is $35.00. It is our office policy to charge a $50.00 per hour fee for every hour of appointment time cancelled or broken without 48 hours advanced notice given.
CONSENT TO PERFORM DENTISTRY 1. I hereby authorize and direct the dentist(s) of Kim Hickey, D.D.S. and/or dental auxiliaries of his/her choice, to perform dental treatment or oral surgery, procedures, including the use of any necessary or advisable local anesthesia, radiographs (xrays), or diagnostic aids. 2. I understand that there are risks involved in this treatment and hearby acknowledge that these risks will be explained to me, that I will have an opportunity to ask questions regarding the treatment and the risks, and that I fully understand the same. 3. I agree to the use of local anesthesia and the use of nitrous oxide/oxygen analgesia depending on the judgement of the doctor/s. Nitrous oxide/ oxygen may occasionally produce nausea and vomiting. I understand and have been informed of the above risks and complications. 4. There are possible risks and complications associated with the administration of local anesthesia. The most common of these are swelling, bleeding, pain, nausea, vomiting, bruising, tingling, and numbness of the lips, gums, face and tongue, allergic reactions, hematoma (swelling or bleeding at or near the injection site), fainting, lip and cheek biting resulting in ulceration and infection of the mucosa. I also understand that there are rare potential risks such as unfavorable reactions to medications in respiratory and cardiovascular collapse (stopping of breathing and heart function) and lack of oxygen to the brain that could result in coma or death. I understand and have been informed of the above risks and complications. 5. I will be advised that the success of the dental treatment to be provided will require that the patient and the parents follow post-operative and post-care instructions of the dentist. I agree that the success of the treatment requires that all post-operative and post-care instructions be followed and that regular office visits as scheduled by my dentist and his/her auxiliaries must be maintained. 6. I hereby state that I have read and understand this consent, and that all questions about the procedures will be answered in a satisfactory manner, and I understand that I have the right to be provided answers to questions which may arise during and after the course of my treatment. 7. I further understand that this consent will remain in effect until such time that I choose to terminate it. : Patient s Name: Parent or Guardian: Relationship: Witness:
NOTICE OF PRIVACY POLICY I understand that, under the Health Insurance Portabitity & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health Information. I understand that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment ffom third-party payers. Conduct normal healthcare operations such as quality assessments and physician certifications. I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. : Patient s Name: Parent or Guardian: Relationship: OFFICE USE ONLY I attempted to obtain the patient's signature in acknowledgement on this Notice of Privacy Practices acknowledgement, but was unable to do so as documented below: : Initials: Reason:
SMILE EVALUATION Name 1. Do you have any problems with your teeth? Yes No 2. Any parts of your mouth sensitive to pressure or irritants (hot, cold, sweets)? Yes No 3. Do you have a bad taste in your mouth or mouth odor? Yes No 4. When was the last time you had your teeth cleaned in a dental office? 5. Do your gums bleed? Yes No 6. Have you ever been diagnosed with gum disease or treated for it? Yes No 7. Have you ever been diagnosed with oral cancer or treated for it? Yes No 8. Is there anything about the appearance of your teeth that you would like improve or enhanced? 9. Would you like your teeth to be straighter? Yes No 10. Do you have spaces between your teeth that you would like closed? Yes No 11. Do you have missing teeth that you would like to replace? Yes No 12. Do you have old silver fillings that you would like to replace with tooth colored fillings? Yes No 13. What is it that you want for your overall oral health?