PATIENT HEALTH HISTORY

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PATIENT HEALTH HISTORY Patient Name Today s Date Birthdate DENTAL HISTORY Reason for Today s Visit Are you having dental pain now? Former Dentist Date of last dental visit Last x-rays Check (!) if you have had problems with any of the following: Bad Breath Bleeding Gums Clicking or popping jaw Food collection between teeth Grinding Teeth Loose teeth or broken fillings Periodontal Treatment Difficult extractions Sensitivity to hot Sensitivity to cold Sensitivity to sweets Pain with biting Sores or growths in your mouth Canker sores or cold sores Dry mouth Head, neck or jaw injury How often do you floss? How often do you brush? Do you like the color of your teeth? (Y/N) What would you like to change about your smile? MEDICAL HISTORY Physicians Name Date of Last visit Have you had any serious illnesses or operations? (Y/N) If yes, describe Are you currently under medical treatment? (Y/N) If yes, describe Has your physician ever recommended that you take antibiotics prior to your dental visits? (Women) Check (!) if you are: Pregnant? Due Date Nursing? Taking birth control pills? Check (!) if you have or have had any of the following: Acid Reflux/GERD Anemia Angina (Chest pain) Arthritis, Rheumatism Artificial Heart Valve Artificial Joints Asthma Back Problems Bipolar Disorder Blood Disease Cancer Chemical Dependency Chemotherapy Circulatory Problems Depression Diabetes Epilepsy/seizures Fainting Glaucoma Heart Attack Heart Murmur Heart Problems Heart Surgery Hemophilia Hepatitis High Blood pressure HIV/AIDS Impaired Hearing Impaired Vision IV Bisphosphonate use Kidney Disease Liver Disease Low Blood Pressure Mental Disorder Mitral Valve Prolapse Osteoporosis Pacemaker Radiation Treatment Respiratory Disease Rheumatic Fever Scarlet Fever STDs Steroid treatments Stroke Thyroid Problems Tuberculosis (Active) Ulcer Other Do you: Smoke tobacco Chew tobacco Use marijuana (recreational or medicinal) Use other drugs MEDICATIONS Medications you are currently taking: ALLERGIES!Aspirin/Tylenol/Ibuprofen!Penicillin!Codeine!Local Anesthetic!Sulfa Drugs!Latex!Other SIGNATURE The above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of her staff responsible for any errors or omission that I may have made in the completion of this form. Signature Date

PATIENT INFORMATION Today s Date Patient Name Birthdate Status (circle one): Minor Single Married Divorced Separated Address City State Zip Home Phone Cell Phone Work Phone Spouse or Parent s Name Person to Contact in Case of Emergency Phone How did you hear about our office? RESPONSIBLE PARTY (Person responsible for account, if different than above) Name Relationship to patient Address Phone INSURANCE INFORMATION Name of Insured Relationship to patient Birthdate Social Security Number (required for some insurances to file claims) Name of Employer Insurance Company Group # Union or Local # Ins. Co. Address Phone number on card Do you know your deductible? How much you have used? Maximum annual benefit? Additional/Secondary Insurance? Yes No (If so, we will provide you with a secondary form for the additional insurance) HIPAA Privacy Policy I have been given the opportunity to review the office HIPAA Privacy Policy and am aware that I have access to a copy at any time. I have read and understand the office HIPAA Privacy Policy (Initial) I have been offered a copy of the office HIPAA Privacy Policy (Initial) Signature Patient, parent, or guardian Date

Records Release Request Date: To: (Doctor/Physician) Address: City: State: Zip Phone: Fax: I authorize the release of my dental records relevant to dental treatment (x-rays, chart notes, periodontal charts), or copies of such, and request that they be released to: 102 N Kenwood, Lower Level Please email all records to: Print name of patient Date of Birth Signature (patient, parent, or guardian)

Consent to Perform Dentistry I hereby authorize and direct Dr. Erin M. Prach D.D.S. to perform the following dental treatment or oral surgery procedure(s), including the use of any necessary or advisable local anesthesia, radiographs (x-rays) or diagnostic aids: Consult with examination for future treatment Preventative hygiene treatment (prophylaxis) and the application of topical fluoride Application of sealants to the groves of the teeth Treatment of diseased or injured teeth with dental restorations (fillings and crowns) Replacement of missing teeth with dental prosthesis (ex. Bridges, partials, dentures) Removal (extraction) of one or more teeth Treatment of diseased or injured oral tissue (hard and/or soft) Root canals Postponing or delaying treatment at this time I understand that there are risks involved in this treatment and hereby acknowledge that these risks will be explained to me. I will have an opportunity to ask questions regarding the treatment and the risks, and that I fully understand the same. I will be advised that the success of the dental treatment to be provided will require that the patient and or parents or guardian of patient to follow 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 the regular office visits are scheduled by my dentist and her auxiliaries must be maintained. I recognize that during the course of treatment unforeseen circumstances may necessitate additional or different procedures from those discussed. I will then be informed of any additional procedures or changes that are deemed necessary for desirable oral health and wellbeing, in the professional judgment of the dentist. There are possible risks and complications associated with the administration of local anesthesia, sedation, and drugs. The most common of these are swelling, bleeding, pain, nausea, vomiting, bruising, tingling, and numbness of lips, gums, face, and tongue, allergic reaction, hematoma (swelling or bleeding at/or near injection site), fainting, lip or cheek biting resulting in ulceration and infection of mucosa. I also understand that there are rare potential risks such as unfavorable reactions to medications causing respiratory depression and/or cardiovascular collapse. (Slow and shallow breathing decreasing oxygen in the body, or a sudden loss of effective blood flow due to heart or vessel factors) and lack of oxygen to the brain that can result in coma or death. I understand and have been informed of the above risks and complications. Consent page 1

I agree to the use of local anesthesia and the use of nitrous oxide/oxygen analgesia depending on the judgment of the doctor. Nitrous oxide/oxygen may occasionally produce nausea and vomiting. I am also aware that the nose piece used to administer the nitrous oxide/oxygen leaves an indentation or ring around the nose, which disappears shortly after the procedure. I understand and have been informed of the above risks and complications. I hereby state that I have read and understand this consent, and that all questions about the procedure will be answered in a satisfactory manner; and I understand that I have the right to be provided an answer to the questions which may arise during and after the course of my treatment. I further more understand that this consent will remain in effect until such time that I choose to terminate it. Patient s Name: Name of Parent or Guardian (minors only): Signature of Patient or Parent/Guardian: Date: Consent page 2

Patient Financial Responsibility Patient s name: Payment options: 1. Cash 2. Check and Money Orders 3. All major Credit Cards We will bill your insurance company as a courtesy, but the entire bill is the patient s responsibility. Our insurance estimates are based on information your insurance provider has given us, and they are not a guarantee that your services will be covered. It is up to the patient to resolve any conflicts with their insurance carrier. If the patient is a minor, the custodial parent is legally liable for any bills incurred in this office. Payment is due at the time of service. If we are billing insurance as a courtesy we will ask you pay the estimated patient portion, and we will send you a statement if there are any amounts outstanding after receiving payment from your insurance carrier. We will accept payment of half the amount of estimated patient portion for dentures, partials, crowns, and bridges on the start date of the procedure. We will collect the second half upon placement or delivery. Finance charges will be applied to any outstanding balance at months end at the rate of 1.80% per month until balance is paid. A returned check fee of $30 will be added to your balance if your check is returned to us. You are responsible for your balance and the returned check fee. I understand that I am responsible for all debts incurred. If my account is assigned to a collection agency after failure to pay on account, I understand that I am responsible for all attorney fees, court costs, or delinquency fees that may be incurred during the collection of my debt. I understand that the delinquency fee will be equal to 35% of the principal amount owed. Signature of Responsible Party Date

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