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* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
* Your assessment is very important for improving the workof artificial intelligence, which forms the content of this project
WELCOME ABOUT YOU Today’s Date: _____/______/______ File #: __________ INSURANCE INFO Patient Name: _______________________________________ LAST FIRST MI What You Prefer To Be Called: ____________ Male Female Primary Dental Insurance Birth date: _____/_____/_____ Age: _____ SS#: ____________ Co. Name: _________________________________________ Mailing Address: ______________________________________ Address: ___________________________________________ ____________________________________________________ ___________________________________________________ CITY STATE CITY ZIP STATE ZIP Home Phone #: _______________________________________ Phone #: ___________________________________________ Work Phone #: _______________________ Ext: ____________ Insured’s SS#: ______________________________________ Other Phone #s: ______________________________________ Group # (Plan, Local, or Policy #): _______________________ E-mail Address: ______________________________________ Insured’s Name: _____________________________________ Referred By: _________________________________________ Relation: __________________ Date of Birth: ____/____/____ Employer: _____________________ How Long? ___________ Insured’s Employer: __________________________________ Employer’s Address: ___________________________________ ____________________________________________________ CITY STATE Secondary Dental Insurance Co. Name: _________________________________________ ZIP Occupation: __________________________________________ Address: ___________________________________________ Status: __________________________________________________ Minor Single Married Divorced Separated Widowed Spouse’s Name: ______________________________________ Do you have children? Yes No How many? _____ CITY STATE ZIP Phone #: ___________________________________________ Insured’s SS#: ______________________________________ Group # (Plan, Local, or Policy #): _______________________ ACCOUNT INFO Insured’s Name: _____________________________________ Relation: __________________ Date of Birth: ____/____/____ Insured’s Employer: __________________________________ Person ultimately responsible for account Name: _______________________________________ Relation: _____________________________________ Billing Address: ________________________________ IN EVENT OF EMERGENCY _____________________________________________ CITY STATE Whom should we contact? _________________________________ ZIP SS#: _________________________________________ Relation: ________________________________________________ Drivers License #: ______________________________ Home Phone #: ___________________________________________ Work Phone #: _________________________________ Work Phone #: ___________________________________________ Payment method: Who is your Medical Doctor? ________________________________ Cash Check ________________________________ / ____________ M.D.’s Phone #: __________________________________________ Credit Card - Enter card # above (if accepted) ______ (INITIAL) I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid by my insurance company (if offered at this office). PLEASE CONTINUE DENTAL INFO Reason for today’s visit: Consultation Emergency Are you in pain? No Yes, How Long? ______________________ Please indicate any of the following problems: Discomfort, clicking or popping in jaw Lost/broken Filling(s) Stained tooth Red, swollen or bleeding gums Teeth grinding Locking jaw Sensitive tooth, teeth or gums Ringing in ears Bad breath Blisters/Sores in or around the mouth Broken/Chipped tooth Other: ____________________ Do you require pre-medication? Yes No Don’t know Dentist: ______________________________________________________________ (_______) _____________________________ Name Phone# MEDICAL HISTORY Have you taken any medication or drugs during the past two years?………………………………………….……..Yes No Are you taking any medication, drugs or pills now?………………………………………………………………….….Yes No If yes, please list name and dosage: __________________________________________________________ Have you ever taken the diet pills Fen-Phen, Pondiman, or Redux for weight loss? ……………………………… Yes No Are you aware of having an allergic (or adverse) reaction to any medication or substance?…………………..…Yes No If yes, please list: _________________________________________________________________________ Have you been a patient in the hospital during the past five years?………………………………………………..….Yes No Indicate which of the following you have had or have at present. Check “yes” or “no” to each item: Heart (Surgery, Disease, Attack) Yes No Ulcers……………. Yes No Hepatitis A, B, C……………… Yes No Chest Pain……………………..… Yes No Diabetes………… Yes No Venereal Disease……….……. Yes No Congenital Heart Disease…….... Yes No Thyroid Problems Yes No A.I.D.S…………………………. Yes No Heart Murmur……………………. Yes No Glaucoma…….…. Yes No H.I.V. Positive…………………. Yes No High Blood Pressure……………. Yes No Contact Lenses… Yes No Cold Sores/Fever Blisters…… Yes No Mitral Valve Prolapse………….... Yes No Emphysema……. Yes No Blood Transfusion……………. Yes No Artificial Heart Valve………….…. Yes No Chronic Cough…. Yes No Hemophilia………………….…. Yes No Heart Pacemaker……...………... Yes No Tuberculosis……. Yes No Sickle Cell Disease…………… Yes No Rheumatic Fever…………...…… Yes No Asthma………….. Yes No Bruise Easily………………….. Yes No Arthritis/Rheumatism……………. Yes No Hay Fever………. Yes No Liver Disease…………………. Yes No Cortisone Medicine……………… Yes No Latex Sensitivity.. Yes No Yellow Jaundice………………. Yes No Swollen Ankles………...….…….. Yes No Allergies or Hives Yes No Neurological Disorders………. Yes No Stroke…………………………….. Yes No Sinus Trouble….. Yes No Epilepsy or Seizures…………. Yes No Diet (Special/Restricted)…...…... Yes No RadiationTherapy Yes No Fainting or Dizzy Spells……… Yes No Artificial Joints (hip, knee, etc.)… Yes No Chemotherapy….. Yes No Nervous/Anxious……………… Yes No Kidney Trouble…………………... Yes No Tumors………….. Yes No Psychiatric/PsychologicalCare Yes No Do you use more than two pillows to sleep?………………………………………………………………………………Yes No Have you lost or gained more than 10 pounds in the past year?……………………………………………………….Yes No Do you have or have you had any disease, condition, or problem not listed?……………………………………...…Yes No If yes, please list: _____________________________________________________________________________________________ Women: Are you: Pregnant? Yes Months_______ No Nursing? Yes No Taking birth control pills? Yes No AUTHORIZATION We invite you to discuss with us any questions regarding our services. The best dental health services are based on a friendly, mutual understanding between provider and patient. Our policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. If account is not paid within 90 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and any other expenses incurred in collecting your account. I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims. I understand the above information and guarantee this form was completed correctly and to the best of my knowledge, and understand it is my responsibility to inform this office of any changes to the information I have provided. Update Signature__________________________________________ Date_______/_______/______ ______ __/__/__ Adult Patient Parent or Guardian Spouse Initials Date ______ __/__/__ Presented by _______________________________________ Date______/_______/______ Initials PLEASE CONTINUE Endodontics ● E ● , ● . . ● Fax . . Date FINANCIAL INFO ABOUT FINANCIAL ARRANGEMENTS, THIRD PARTY PAYMENTAND DENTAL INSURANCE Payment or co-payment for services is due at the time services are rendered. We accept cash, checks, credit cards, and bank debit cards. We have contracted to accept Visa, Master Card, American Express, and Discover. We will be glad to help you process your insurance claim form for your reimbursement. Provided you give us the proper information the dental insurance form will be ready by the time treatment is completed. Your understanding about the following information is important to us: Your insurance or third party contract arrangement is between you, your employer and the insurance company. We may not be a contracted provider for your plan. Not all services are covered benefits in all contracts. Some insurance companies arbitrarily select certain services they will not cover. Promptness in processing your claim varies from one insurance company to another; it may take 30-60 days to process your dental claim. We have set fees for each procedure, unless we are a contracted provider for your plan. Perhaps the most misunderstood part of your coverage is known as the usual customary and reasonable (UCR) charges. The UCR is the maximum fee that your policy will cover. This dollar figure varies with each dental policy and is determined in large part by the amount of coverage purchased by your employer. Stated simply, the lower the UCR, the more your out- of- pocket expense for dental care. That is why following your initial call to this office; we encouraged you to check with your insurance company. We must emphasize that as dental care providers, our relationship is with you, not your insurance company. While filing of insurance claim forms is a courtesy that we extend to our patients, all charges are your responsibility from the date services are rendered. If you have any questions about the above information, please do not hesitate to ask us. We are here to help. Patient’s signature ________________________________________ Date______/______/______ Adult Patient Parent or Guardian Spouse CONSENT FOR ENDODONTIC THERAPY Endodontic (root canal) therapy is a commonly performed and generally safe dental procedure to save a tooth, which might otherwise need to be removed. We would like our patients to be informed about the procedure, the possible risks and alternative treatment options. RISKS: The risks of treatment include (but are not limited to) complications resulting from the use of dental instruments and materials, drugs, sedation medicines, analgesics, anesthetics and injections. These may include pain, facial swelling, or bruising, bleeding, postoperative infection, which could require hospitalization, reaction to anesthetics, jaw muscle pain and spasms, temperomandibular joint (TMJ) problems, jaw fracture, numbness or tingling of the lip, chin, tongue, gums, cheeks or teeth (which is generally temporary but can in rare instances be permanent), sinus perforation or inflammation, allergic reactions, injury to the mouth or eyes, alterations of taste, changes in occlusion (bite), and loss of teeth, which could require hospitalization. RISKS MORE SPECIFIC TO ENDODONTIC THERAPY: Include the possibility of instruments being dislodged inside the tooth, perforation (unintended holes), fracture or loosening of the tooth which may lead to its loss, damage to crowns, bridges, veneers, or existing fillings. During treatment unanticipated complications may be discovered which make a successful outcome less likely or impossible, or which may require dental surgery to correct. These may include blockages of the canals due to fillings or prior treatment, natural blockages (calcifications), broken instruments, severely curved or narrow root canals, periodontal (gum) defects requiring followup periodontal therapy, or fractured teeth. PRESCRIBED MEDICATIONS: May cause allergic reactions, nausea, vomiting, diarrhea, or gastrointestinal problems requiring medical treatment. Pain medications can cause drowsiness or lack of awareness or coordination, which may be influenced by the use of alcohol, tranquilizers, sedatives and other drugs. It is advisable not to operate a motor vehicle or dangerous device while taking these medications. Prescription drugs may interact or interfere with other drugs you are taking, such as cholesterol reducing medications and birth control pills. OTHER TREATMENT CHOICES: As an alternative to root canal therapy, you may decide to have the tooth extracted, wait for more definitive symptoms to develop, or choose no treatment. Extraction and no treatment also pose risks, which may include pain, swelling, spread of infection, and/or loss of teeth. CONSENT: My signature below constitutes my acknowledgment that I have read the above carefully and consent to the procedure(s) deemed necessary or advisable by the doctors of Treasure Coast Endodontics. I understand that root canal therapy is not always successful and on occasion a tooth, which has had root canal therapy, may require re-treatment, surgery or extraction. I also understand that upon completion of treatment, I must return to my general dentist for permanent restoration of my tooth. Patient’s Name (please print) __________________________________________________________ Patient’s Signature __________________________________________ Date_______/_______/_____ Adult Patient Parent or Guardian Spouse Presented by _______________________________________________ Date_______/_______/_____ Endodontics ● S ●S , ● . . ● Fax . .