Welcome to Dr Jamie Italiane-DeCubellis s office

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Welcome to Dr Jamie Italiane-DeCubellis s office Thank you for choosing our healthcare team for your dental needs. Our goal is to make your experience here pleasant and to provide you with high-quality dental care. To help us meet all of your dental needs, please fill out this form completely in ink. If you have any concerns or questions at any point in our relationship, please let us know we are happy to help Patient Information Date Name Age Social Security # - - Birthday / / Home Work Cell E-Mail How would you like us to confirm your appt? Patients Address City State Zip Circle one: Minor Single Married Separated Divorced Widowed Life Partner Patients Employer (if adult) Who can we thank for referring you or how did you hear of us? Emergency contact? Relationship Phone# Responsible party (if other than patient) Relationship to Patient Phone # Address City State Zip Insurance information Primary Dental Insurance Member ID# Subscribers Name Subscribers DOB Relationship to patient Social Security# - - Insurance information Secondary Dental Insurance Member ID# Subscribers Name Subscribers DOB Relationship to patient Social Security# - - You are responsible for making us aware of any changes in your dental insurance. If we are not informed of the changes, it may change the cost of a procedure that has already been treatment planned. We normally do not bill, but if insurance doesn t pay what is expected, you may get a bill after insurance pays. Please be aware that some insurance plans only cover 1 exam per year, so if you come in for a problem the cost for the exam could be out of pocket. If we have preauthorized under your previous insurance and you change insurance in the middle of procedure we would need to preauthorize under the new insurance to know if they will cover something such as a crown or partial. Also, please let us know if you have been to another dentist, oral surgeon, periodontist or endodontist, as this may also change what your insurance would pay. Please sign stating that you have read and understand the above statement. Print: Signature

Dr Jamie Italiane-DeCubellis & Associates Medical and Dental History Although dental personnel primarily treat the area in & around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you are taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Patients Name: DOB Medical Doctors Name Phone Undergoing any medical treatment at this time? If so for what List reason for hospitalization Do you smoke? Y/N How long How much daily Do you chew tobacco Y/N Drink Alcohol? Y/N Do you use controlled substances? Y/N If yes, please list Are you allergic to the following? Please circle Other allergies not listed Latex Codeine Local anesthetics Sulfa drugs Metal Topical anesthetic gel Antibiotics? Are you taking Aspirin or blood thinner daily? If yes, describe Have you ever taken or are taking Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Y/N List of Medications taking over the counter and prescription drugs Please circle the following if apply: AIDS/HIV Positive Congenital Heart Heart Attack Liver Disease Sickle Cell Disease Abnormal Bleeding Diabetes Heart Surgery Low Blood pressure Sinus Problems Alcohol Abuse Difficulty Breathing Hemophilia Mitral Value Prolapse Stroke Allergies Drug Abuse Hepatitis A Organ Transplant Thyroid Problems Anemia Emphysema Hepatitis B Pacemaker Tuberculosis Angina Pectoris Fainting Spells High Blood Pressure Psychiatric Problems Ulcers Arthritis Fever Blisters Joint Replacement Radiation Therapy Venereal Disease Artificial Heart Frequent Headaches Kidney Problems Rheumatic Fever Yellow Jaundice Asthma Glaucoma Latex Allergy Seizures GERD Blood Transfusion Joint Screws/Pins Cancer Chemotherapy Shingles Are there any other medical conditions that are not listed? What brings you to our office? Why did you leave your previous dentist? Any bleeding or pain in your mouth? Pain or clicking in your Jaw Joint? Do you clench or grind your teeth? Do you have frequent headaches? Women only: Pregnant/trying to get pregnant? Taking Oral Contraceptives? Y/N To the best of my knowledge, the questions on the form have been accurately answered. I understand that providing incorrect information can be dangerous to my (patient s) health. It is my responsibility to inform the dental office of any changes in medical status. Signature of Patient, Parent or Guardian Date

CANCELATION POLICY 24 HOURS NOTICE IS REQUIRED FOR RESCHEDULING OR CANCELING APPOINTMENT WE HAVE RESERVED THIS TIME FOR YOU WE NEED THE OPPORTUNITY TO LET ONE OF OUR OTHER PATIENTS TO COME IN AT THAT TIME IF 24 HOUR NOTICE IS NOT GIVEN THERE WILL BE A $50.00 CHARGE THAT WOULD NEED TO BE PAID BEFORE MAKING ANOTHER APPOINTMENT YOU CAN INFORM US BY TEXT MESSAGE, E-MAIL OR PHONE HEALTHYTEETHRI@GMAIL.COM 401-828-7070 SIGNATURE PRINT NAME DATE

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