REGISTRATION FORM / MEDICAl- DENTAL HISTOR Residence Address: ------------------------------------------------------- Telephone Number: Referred By: Family Members in the Practice: Preferred Tim e for Appointments: SSN: --------------------- Marital Status: S M D W Spouse's Name: DOB: ------------------------- If Minor, Name of Guardian: Address & Telephone: Person Responsible for Account (If other than patient): Relationsh ip to Patient: Billing Address (If other than above): Occupation: Employer' 5 Name & Telephone : EMERGENCYNOTIFICATION Name & Telephone: Will you receive calls at work? Y / N
Patient Consent to receive Mail and/or Telephone Messages Please Print (last Name) (First Name) (M.I.) Do we have your permission to: Send a recall appointment reminder to your home? Leave appointment, billing or dental information on your Answering machine/voicemail/e-mail? y y N N I give permission to share appointment, billing, or dental information with the person named below: Name: Signature of Patient / Parent or Legal Guardian Date Acknowledgement of Receipt of Notice of Privacy Practices I have received a copy of the Notice of Privacy Practices with an effective date of 2009. Signature of Patient / Parent or Legal Guardian Date ria G &5'fF 46S& Ph i H 3 j I k5" f'.,.&. ~ SF5. HIPPA CONSENT Pagel
1. Name, address & phone number of your physician? 2. Date of last visit to your doctor Purpose of visit'-- 3. Do you suffer from any disability? If yes, describe. 4. Have you ever, or do you now take illegal drugs? If yes, what drugs and when taken? *Note: There are drugs and medications used in routine dental care that are incompatible with several illegal drugs. The effect of the combination may be dangerous to your health and may be fatal. 5. List all medications you are now taking or have taken previously on a regular basis, describe the strength and purpose for each: "Note: There are many drugs and medications when mixed with other drugs and/or medications may cause complications some of which may result in dangerous health problems. Information about your current use of drugs and medications is essential. 6. Have you lost weight recently? If yes, describe Have You Ever Had or Been Treated For: 7. Have you ever had a serious injury to your head or neck? If yes, describe 8. Are you on a special diet? If yes, for what reason and describe 9. Do you smoke? If yes, describe type and quantity 10. Have you consulted or been treated by a psychiatrist, psychologist, or counselor? If yes, when and describe 11. Do you consume any alcoholic beverages? If yes, how much and how often? 12. For children under 10 years old. Was the child born by Cesarean Section? 13. Do you ever notice that your feet and/or ankles are swollen? 14. Are you aware of any swollen glands in your neck?
Have you ever had the following (check all that apply): Heart attack HeartSurgery Heart Murmur Pacemaker ScarletFever Hepatitis CancerTreatment Chemotherapy HIV/AIDS Shingles FeverBlisters ColdSores Stroke SinusTrouble Diabetes Tuberculosis Ulcers CoIitis Anemia Asthma Emphysema Hemophilia/Bleeding Glaucoma VenerealDisease High/LowBlood Pressure BloodTransfusion Bisphosphonatetreatment (ie Zometa,Aredia) Hospitalizedor Major Operation, Mitral ValveProlapse Rheumaticfever Kidneyproblems Radiation Artificial Joint Artificial Valve Epilepsy/Siezures PsychiatricProblems Drug/AlcoholDependence Arthritis, Rheumatism Fainting Difficulty Breathing Severeor FrequentHeadaches Are you Allergic to or have had difficulty with any of the following substances: Penicillin Aspirin sulfa Other Drugs Tetracycline Codeine Erythromycin Latex DentalAnesthetic Do you exercise regularly? (y/n), If YESwhat do you enjoy doing? For Women: Areyoutakingbirth controlpills? Areyoupregnant? Areyounursing? *Are there any other problems about your health of which you aware? 3lP-oe. a o
Dental History 1. Name of previous dentist Date of your last visit? 2. Reason for your last visit (or series of visits) 3. Do you have any of your X-rays or dental records? 4. Chief Dental Complaint? In respect to any previous dental treatment have you: 5. Ever fainted? 6. Had an allergic reaction? 7. Had abnormal bleeding? 8. Any other complications during or following dental treatment? If yes, describe. 9. Do your gums bleed on brushing or eating? 10. Does food catch between your teeth? 11. Have your teeth shifted, are there spaces between your teeth now where there were none, are your teeth flaring, or are some of your teeth becoming loose? 12. Are any of your teeth sensitive to heat, cold, or pressure? 13. Do you grind your teeth or clench your jaws? 14. Do you have pain or clicking in the jaw joint in front of your ear? 15. Have your jaw muscles ever been sore? 16. Are there any sores or growths in your mouth? 17. Doanyofyourteethache? 18. Do you have any other dental complaint? To the best of my knowledge, the foregoing questions have been answered. NOTE: A change in your health status should be reported to the office immediately "I understand that should there be a change in my health during my dental treatment, I am to inform the dentist at the earliest possible time." Patient's Initials Dentist's Initials 41Page
Permission to Release Health Information I grant the right to the dentist to release health information obtained from me, and information about my dental treatment to third party payers, and/or health practitioners. Person completing the form: Signature: Witness: Print Name: Of other than patient, indicate relationship Date The information on these pages is true to the best of my knowledge. The undersigned authorizes the doctor to take X-rays, study models, photographs, or other diagnostic materials deemed appropriate by the doctor to make a thorough diagnosis of my dental health condition. I authorize the doctor to perform any and all forms of treatment, medication, or therapy that may be indicated in connection to the services required for my dental health. I understand that the doctor will discuss treatment before it is initiated. I further authorize and consent that the doctor choose and employ such assistance as deemed fit. I understand that the responsibility for payment for professional services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless written financial arrangements have been made and signed by me. In the event of default I promise to pay interest on the indebtedness, together with any collection costs and attorney fees as may be required to effect collection. All past due amounts are assessed 1.5% per month SIGNED DATE~ 51Page
Dental Insurance and Agreement As a service to our valued patients WE SUBMIT TO ALL INSURANCECOMPANY PLANSAND FILEALL INSURANCECLAIMS FORYOU ELECTRONICALLY. A SIGNED AND COMPLETEDINSURANCEFORM IS REQUIREDFORALL OUR FILES. The responsibility of the insurance company is to you and it is important that you insure you are reimbursed properly. Fees for services provided to insured patients are the usual and customary fees charged to all patients for similar services. Your policy may base its allowance on a fixed fee schedule determined solely by your insurance company. The percentage of the fee paid may therefore be different than the percentage stated by your insurance company or different from the percentage listed in your benefit booklet. We have developed fees based on services provided and do not participate with insurance carriers in determining appropriate fees. In deciding whom they should participate with the doctors have selected YOU. We will doour very best to be certain that you receive all benefits due to you from your insurance carrier. If you have any questions please contact our office at (301) 907-8201. I wish to have my claims filed electronically. I have read the above completely and agree to the arrangements stated. SIGNED DATE
S/v\ILE REGISTRATION- FORM/MEDICAL-DENTAL HISTORY Instructions "I understand that honest answers to the questions stated below are important to the provision of dental care, and that I will answer them to the best of my ability. I have been informed that if I am uncertain about the question related to my health status. I must discuss the problem with the doctor or a member ofthe office staff. I understand that all questions must be answered. I have been assured that the information I provide will not be released without my express permission" Patient's Initials, Dentist's Initials To receive treatment in this office you must answer all answers on this history form. The questions asked relate directly to the safe and effective treatment office-to the best of your ability honest answers must be given. you are to receive in the If you are unsure of the question, unsure of your answer, or whether the question relates to your medical condition, you are to discuss the matter with the doctor. Some of the questions may not relate to you or your medical condition; in that event you are to write "N/ A" (not applicable) in the space provided. All questions must be answered and written in ink. To properly evaluate your current health status it may be necessary for the dentist to contact your physician. Included on this form is "Permission to Release Information." You are asked to sign it in the presence of a member of the office staff. ALL INFORMA TlON YOU SUPPLY TO OFFICE ON THIS FORM, AND THE SUBSEQUENT INTERVIEW BY THE DENTIST AND INFORMA TlON RECEIVED FROM YOUR PHYSICIAN OR ANY OTHER SOURCE WILL BE HELD IN THE STRICTEST CONFIDENCE, AND WILL NOT BE DISCLOSED WITHOUT YOUR EXPRESSAND WRITTEN PERMISSION.