ATWOOD FAMILY DENTAL DENTAL REGISTRATION AND HISTORY

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Transcription:

ATWOOD FAMILY DENTAL DENTAL REGISTRATION AND HISTORY PATIENT INFORMATION Date SS/HIC/Patient ID# Patient Name Responsible Party Address City State Sex M F Age Birthdate Married Widowed Single Minor Separated Divorced Partnered for yrs. Patient Employer/School Employer/School Phone ( ) Spouse s Name Birthdate Spouse s Employer Referred by whom? DENTAL INSURANCE Subscriber Name Birthdate SS# Phone # Relationship to Patient Insurance Co. Address Group # Is patient covered by additional insurance? Subscriber s Name Birthdate SS# Relationship to Patient Insurance Co. Address Group # Are you interested in? Whiter teeth Straighter teeth Other changes to your smile (specify) CONTACT INFORMATION Home ( ) Work ( ) Cell ( ) Email Best time to reach you IN CASE OF EMERGENCY, CONTACT (Specify someone not living in your household) Name Relationship Home ( ) Work ( ) Cell ( ) Reason for today s visit Former Dentist Date of last dental visit Date of last dental x-rays Please circle yes or no to indicate if you have any of the following: Bad Breath Bleeding Gums Blister on lips/mouth Burning sensation on tongue Broken teeth or fillings Chew on one side of mouth Cigarette, pipe or cigar smoking Clicking or popping jaw Dry Mouth Fingernail biting Food collection between teeth Foreign objects Grinding teeth Gums swollen or tender Jaw pain or tiredness Lip or cheek biting Loose teeth Mouth breathing Mouth pain, brushing Orthodontic treatment Pain around the ear Periodontal treatment Sensitivity to cold Sensitivity to heat Sensitivity to sweets Sensitivity to biting Sore or growth in mouth TEMP BP RESP ASA I II III IV

HEALTH HISTORY Physician s Name: Date of last visit: Have you ever taken any of the group of drugs collectively referred to as fen-phen? These include the combination of Lonimin, Adipex, Fastin (brand names of Phentermine), Pondimin (Fenfluramine) and Redux (Dexfenfluramin). CIRCLE YES OR NO TO INDICATE IF YOU HAVE HAD ANY OF THE FOLLOWING: AIDS/HIV Epilepsy Respiratory Disease Anemia Fainting/dizziness Rheumatic Fever Arthritis, Rheumatism Glaucoma Scarlet Fever Artificial Heart Valves Headaches Shortness of breath Artificial Joints Heart Murmur Sinus Trouble Asthma Heart Problems Skin Rash Back Problems Hepatitis Type Special Diet Bleeding abnormally with Herpes Stroke Extractions or surgery High Blood Pressure Swollen Feet/Ankles Blood Disease Jaundice Swollen Neck Glands Cancer Jaw Pain Thyroid Problems Chemical Dependency Kidney Disease Tonsillitis Chemotherapy Liver Disease Tuberculosis Circulatory Low Blood Pressure Tumor/Growth on head Congenital Heart Problems Mitral Valve Prolapse or neck Cortisone Treatments Nervous Problems Ulcer Cough, persistent or bloody Osteoporosis Weight Loss-unexplained Diabetes Pacemaker Trouble Sleeping Emphysema Psychiatric Care Snoring Do you wear contact lenses? Radiation Treatment Sleep Apnea MEDICATIONS ALLERGIES List any medications you are currently taking and the Aspirin Local Anesthetic Correlating diagnoses: Barbiturates (Sleeping Pills) Penicillin Codeine Sulfa Pharmacy name: Iodine Other Phone ( ) Latex BY SIGNING BELOW I ACKNOWLEDGE THAT THE ABOVE INFORMATION IS ACCURATE: PATIENT SIGNATURE DATE OFFICE USE ONLY BP: PULSE:

ATWOOD FAMILY DENTAL FINANCIAL POLICY Thank you for choosing our office for your dental needs. We realize that every person s financial situation is different. For this reason, we have worked hard to provide a variety of payment options to help you receive the dental care you need and deserve that allows you to enjoy a healthy, beautiful smile with respect to your budget. Dental treatment is an excellent investment in an individual s medical and psychological care. We are always available to answer your questions or assist you in any way we can. To maintain the practice operations and prevent potential misunderstandings, we ask patients to accept and adhere to the following financial arrangements regarding their dental treatment. OPTIONAL PAYMENT TERMS: 1. PRE-PAYMENT DISCOUNT: If the patient portion is over $1000 we offer a 5% accounting courtesy for patients who pay their portion (that part not expected to be covered by insurance) for the total treatment plan the day the treatment plan is presented. This allows us to arrange all needed appointments in advance and order any materials specific to your needs, and rewards you with a 5% discount. Payment by cash or check is accepted for the discount. 2. MAJOR SERVICE PAYMENT OPTION: We offer a two-payment option for crown, bridge, and denture treatment. We ask that you pay one-half of your payment at or prior to the first appointment and the second half at or prior to the seat appointment. 3. INTEREST DEFERRED TERM LOAN: By arrangement with CareCredit, we offer our patients, upon approval, an interest deferred term loan (up to 12 months) with no down payment, no annual fee, and no prepayment penalty. Generally the application form can be completed online and approval given within a few minutes when applying from your personal computer or mobile phone. Payments are expected either in advance or at the time services are rendered. We accept cash, checks, debit cards, major credit cards (VISA, MASTERCARD, DISCOVER), and CareCredit. Dental insurance policies are an agreement between the insurance company and the policy holder. We accept insurance with the understanding that any payment not received from insurance within 30 days of filing becomes the patient s responsibility. For those patients with secondary insurance, we will continue to file secondary insurance, however, the patient is responsible for payment of services not covered by either insurance. PATIENTS WHO MISS APPOINTMENTS OR CANCEL ON SHORT NOTICE (LESS THAN 24 HRS) WILL BE ASKED TO MAKE A RESERVATION DEPOSIT FOR SUBSEQUENT APPOINTMENTS. PLEASE NOTE THAT APPOINTMENTS CANNOT BE CANCELLED OR RESCHEDULED VIA THE VOICEMAIL. By signing below, you are stating that you agree with the above options and terms and will proceed accordingly. Again, thank you for choosing ATWOOD FAMILY DENTAL. PATIENT SIGNATURE DATE

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES ATWOOD FAMILY DENTAL hereby makes it known that all patient information will remain private, unless it is required or requested to share such information with another attending dentist, doctor, or the patient s insurance company. This is done in compliance with the HIPPA Privacy Practices, and my signature below attests that I have been informed of the Privacy Practices stated in this paragraph. (Signature of Patient, Parent, or Guardian) Date I AUTHORIZE THE FOLLOWING TO PERSON/PERSONS LISTED BELOW TO RECEIVE HEALTH INFORMATION FOR THE FOLLOWING: All health information Physician s Referral Billing or Claims X-rays Appointment Insurance Legal Documents Patient Allergies Consultation/Exam **************** APPOINTMENT SCHEDULING POLICY We understand that unplanned issues can come up and you may need to reschedule an appointment. If that happens, we respectfully ask for scheduled appointments to be rescheduled at least 24 hours in advance. Our doctor and hygienists want to be available for your needs and the needs of all our patients. When a patient does not show up for a scheduled appointment, another patient loses the opportunity to be seen. Although we have always had a policy, circumstances have caused us to enforce a policy of charging for no-show appointments, and those appointments not cancelled with at least a 24 hour notice. There will be a fee of $50.00 per appointment hour assessed if we do not receive a call 24 hours in advance to cancel or reschedule an appointment. Thank you for being a valued patient and for your understanding and cooperation as we institute this policy. This policy will enable to us open otherwise unused appointments to better service the needs of all our patients. Name: Date:

SMILE EVALUATION NAME: DATE: 1. DO YOU LIKE THE WAY YOUR TEETH LOOK? YES NO 2. ARE YOU HAPPY WITH THE COLOR OF YOUR TEETH? YES NO 3. WOULD YOU LIKE FOR YOUR TEETH TO BE WHITER? YES NO 4. WOULD YOU LIKE YOUR TEETH TO BE STRAIGHTER? YES NO 5. DO YOU HAVE SPACES BETWEEN YOUR TEETH THAT YOU WOULD LIKE CLOSED? IF SO, WHERE? YES NO 6. WOULD YOU LIKE YOUR TEETH TO BE LONGER? YES NO 7. DO YOU LIKE THE SHAPE OF YOUR TEETH? YES NO EXPLAIN: 8. DO YOU HAVE MISSING TEETH THAT YOU WOULD LIKE TO REPLACE? YES NO 9. DO YOU HAVE OLD SILVER FILLINGS THAT YOU WOULD LIKE TO REPLACE WITH TOOTH COLORED FILLINGS? YES NO 10. IF YOU COULD CHANGE ANYTHING ABOUT YOUR SMILE, WHAT WOULD YOU CHANGE?

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