Download New Patient Packet

UPTOWN DENTAL
Jeffrey Belz, DDS
642 Uptown Blvd, Suite 160
Cedar Hill, Texas 75104
Phone 469-272-8505 - Fax 469-272-8508
PLEASE MAKE SURE ALL PAGES ARE COMPLETE, SIGNED AND DATED.
Patient’s Name: Last
First
Middle
Address:
Zip Code
City/State:
Social Sec. #
Drivers License#
Date of Birth:
Home#
Work#
Cell#
Pager#
Marital Status:
Male/Female
E-Mail Address:
Employer:
Occupation:
Years Employed:
Spouse’s Name:
Spouse’s Occupation:
Work#
Cell#
If patient is a minor, give parent’s or guardian’s name:
Whom may we thank for referring you to our office?
Responsible Party Information
Name:
Relationship to patient:
Birth Date:
Social Sec. #
Drivers License#
State:
Address:
Zip Code
Home#
Work#
Cell#
Insurance Information
Insured’s Name:
Social Sec. #
Birth Date:
Insured’s Employer:
Insurance Company:
Group#
Phone#
Emergency Information
Name of nearest relative not living with you:
Complete Address:
Phone #
Signature(Parent’s signature, if minor)
Date:
Please list all of your contact numbers incase of an emergency. We need to be
able to contact you; one number may not be enough.
Creating Healthy Smiles For The Entire “Family”
Please make sure ALL pages are complete, signed and dated.
MEDICAL HISTORY
Patient Name:________________________________________Date:___________________
Physician__________________Office Ph#___________Date last exam______________
YES NO
1. Are you under any medical treatment now?
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2. Have you ever been hospitalized for any surgical operation or illness?
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3. Are you taking any medication (s) including non-prescription medicine?
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If yes, what medication (s) are you taking ?________________________________________
4. Have you ever taken Fen-Phen/Redux?
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5. Do you use tobacco/pipe/chew?
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6. Do you use alcohol, cocaine and/or other drugs?
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7. Are you wearing contact lenses?
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8. Do you need antibiotic pre-medication prior to dental work?
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9. Are you allergic to or have you had any reactions to the following?
___Local anesthetics (Novocain) ___Barbiturates
___Aspirin
___Sedatives
___Iodine
___Penicillin ___Erythromycin
___Tetracycline
___Codeine
___Sulfa Drugs
___Latex
___Other_____________________________________
10. Do you have a persistent cough or throat clearing not associated with a known illness
lasting lore than 3 weeks?
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WOMEN ONLY
11. Are you pregnant or think you may be pregnant?
12. Are you nursing?
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13. Are you taking birth control pills/patch/or medication?
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Please make sure all pages are complete, signed and dated.
Do you have or have your ever had any of the following?
__High/Low Blood Pressure
__Heart Disease
__Chest Pains
__Heart Attack
__Heart Murmur
__Cardiac Pace Maker
__Rheumatic Fever
__Stroke
__Easily Winded
__Swollen Ankles
__Angina
__Hay fever/Allergies
__Fainting/Seizures
__Frequently Tired
__Tuberculosis
__Asthma
__Anemia
__Glaucoma
__Radiation Treatment
__Emphysema
__Cancer
__Epilepsy/Convulsions
__Recent Weight Loss/Gain
__Leukemia
__Arthritis
__Diabetes
__Kidney Disease
__Mitral Valve Prolapse
__Hepatitis/Jaundice
__Stomach Troubles/Ulcers
__Excessive Bleeding
__Liver Disease
__Joint Replacement/Implant
__Thyroid Disease
__Respiratory Problems
__Aids or HIV Infection
__Sexually Transmitted Disease
__Other_______________________
PATIENT DENTAL HISTORY
Do you or have your ever had any of the following?
__Bleeding Gums
__Sensitive to Hot/Cold
__Bite Nails/Objects
__Blisters/Abscess in Mouth
__Clenching/Grinding Teeth
__Cold Sores/Ulcers
__Gag Easily
__Missing Teeth
__Loose Teeth
__Sensitive/Infected Gums
__Periodontal Disease
__Jaw Joint Pain
__Pain Around Ears
__Frequent Headaches
__Sensitive to Sweet/Sour
__Braces
__Bites Lips/Cheek
__Difficult Extractions
__Stained Teeth
__Pain in Teeth/Jaw/Ear
__Clicking/Popping in Jaw
__Difficulty Chewing
__Other_______________________
__Other______________________
I certify that I have read and understand the above information. To the best of my
knowledge, the above questions have been accurately answered. I understand that
providing incorrect information can be dangerous to my health.
Signature_________________________________Date________________________________
Signature of Dentist___________________________________________________________
OFFICE POLICY
Payment Options
Our office wants all of our patients to be able to comfortably afford dental care. We proudly offer the following financial
policy so that our patients can have the opportunity to decide which payment option best suits their needs.
1.
2.
3.
Master Card, Visa & debit cards with the logo are accepted.
Cash, checks (established patients only).
PAYMENTS THROUGH CARECREDIT. Outside dental financing (such as Care Credit) upon qualifying, you
will be extended a line of credit for treatment costs by an outside financing company. The qualification process is
simple and can usually be completed within minutes. Several payment options are available, some with no interest.
Payment will be made directly to the financing company.
(Initials) __________
Insurance
Our office understands the value of insurance to our patients and will gladly work with you to get the maximum benefit
available to you. We will accept assignment of benefits. Most dental insurance plans do not cover 100% of the cost of your
treatment. Because of this and the extreme delay in receiving payment from the insurance company, you will be asked to
pay your deductible and your portion of the charges the day of services is rendered. We will ESTIMATE as closely as
possible your coverage, but until we actually receive the payment from the insurance company, it is just an estimate.
We will assist you in dealing with your insurance company, but the ultimate responsibility lies with you. Our estimates are
subject to final approval by your insurance company and could therefore change the amount due to our office.
(Initials) ________
Broken Appointments
Reserved appointment time in any office is limited and valuable. It is extremely important that all patients honor their
appointments. Failure to do so deprives our other patients from receiving needed dental care in a timely fashion.
So that the dentist, our staff and other patients will not be penalized by those who fail to keep scheduled appointments,
our office policy stipulates that failure to give sufficient warning to keep a scheduled appointment, (24 hours advanced
notification), will result in a $50.00 fee being charged. That charge which is in accordance with our dental office’s
broken appointment policy for all of our patients is to be paid prior to the scheduling of any new appointments. The patient
is responsible for payment of this charge.
(Initials)__________
Please feel free to discuss this and other policies with our staff.
(Signature)________________________________________ (Date) ________________
(Witness)_________________________________
DENTAL TREATMENT CONSENT FORM
Please read and initial the items checked below and read and sign the section at the bottom of the form.

Patient Name_______________________________________
1. WORK TO BE DONE

I understand that I am having the following work done: Filling(s)_______Bridge(s)________
Crown(s)_________Extraction(s)_____Impacted teeth removed_______General Anesthesia_______
Prophy(teeth cleaning)___X___Exam____X___Digital Imaging__X___Other_______
(Initials_____)
2. DRUGS AND MEDICATIONS

I understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and
swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reactions).
(Initials_____)
3. CHANGES IN TREATMENT PLAN

I understand that during treatment it may be necessary to change or add procedures because of conditions found while
working on the teeth that were not discovered during examination, the most common being root canal therapy following routine
restorative procedures. I give my permission to the Dentist to make any/all changes and additions as necessary.
(Initials_____)
4. REMOVAL OF TEETH

Alternatives to removal have been explained to me (root canal therapy, crowns, and periodontal surgery, etc…) and I
authorize the Dentist to remove the following teeth__________________________________________________________
and any other necessary for reasons in paragraph #3. I understand removing teeth does not always remove all the infection, if
present, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of
which are pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue
(Paresthesia) that can last for an indefinite period of time (days or months) or fractured jaw. I understand I may need further
treatment by a specialist or even hospitalization if complications arise during or following treatment, the cost of which is my
responsibility.
(Initials_____)
5. CROWNS, BRIDGES, VENEERS, AND CAPS

I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further
understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are
kept on until the permanent crowns are delivered. I realize the final opportunity to make changes in my new crown, bridge, or
cap (including shape, fit, size, and color) will be before cementation.
(Initials_____)
6. DENTURES, COMPLETE OR PARTIAL

I realize that full or partial dentures are artificial, constructed of plastic, metal, and/or porcelain. The problems of
wearing these appliances have been explained to me, including looseness, soreness, and possible breakage. I realize the final
opportunity to make changes in my new dentures (including shape, fit, size, placement, and color) will be the “teeth” in wax”
try-in visit. I understand that most dentures require relining approximately three to twelve months after initial placement. The
cost for this procedure is not included in the initial denture fee.
(Initals_____)
7. ENDODONTIC TREATMENT (ROOT CANAL)

I realize there is no guarantee that root canal treatment will save my tooth, and that complications can occur from the
treatment, and that occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily
affect the success of the treatment,. I understand that occasionally additional surgical procedures may be necessary following
root canal treatment (apicoectomy).
(Initials_____)
8. PERIODONTAL LOSS (TISSUE & BONE)
I understand that I have a serious condition, causing gum and bone inflammation or loss and that it can lead to the loss
of my teeth. Alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. I
understand that undertaking any dental procedures may have a future adverse effect on my periodontal condition..(Initials_____)
I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee
results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have
requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to
my satisfaction. I consent to the proposed treatment.
Signature of Patient____________________________________________________
Date___________________________
Signature of Parent/Guardian if patient is a minor_____________________________
Date___________________________
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
Jeffrey D. Belz, DDS
642 Uptown Blvd., Suite 160
Dallas, Texas 75224
I understand that, under the Health Insurance Portability & Accountability Act of 1996
(HIPPA”), 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 from third-party payers.
●
Conduct normal healthcare operations such as quality assessments and
physician certifications.
I have received, read and understand your Notice of Privacy Practices containing a more
complete description of the uses and disclosures for 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 Private 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 Name
X__________________________________________
Relationship to Patient
X__________________________________________
Signature
X__________________________________________
Date
X__________________________________________
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:
Date:___________________________________
Initials:_________________________________
Reason:___________________________________________________________________________