Download Forms for Luna Dental Sleep Medicine Patients ONLY

Welcome to Suwanee Family Dentistry! We are glad you are going to be a part
of our practice. We value attention to detail and want to be correct and complete,
so please fill out the following information. Thank you!
2566 Lawrenceville Suwanee Rd., Suwanee GA 30024 (678)714-2380
PATIENT INFORMATION
Patient’s last name:
Is this your legal
name?
‰ Yes
‰ No
First:
Middle:
Preferred Name:
Marital Status (circle one)
Birth date:
Single / Mar / Div / Sep / Wid
Street address:
/
Home Phone:
City:
State:
ZIP Code:
Occupation:
Employer:
Age:
Sex:
‰M
/
‰F
Cell phone:
Email Address:
Work phone number:
How did you hear about our office?
How would you like to be contacted for courtesy calls? (circle one) Email / Home / Work / Cell
INSURANCE INFORMATION
Policyholder:
Birth date:
/
Policyholder SSN:
Address (if different):
Home phone no.:
/
(
Employer:
)
Employer phone no.:
(
Insurance Company:
Patient’s relationship to
subscriber:
Insurance phone number:
‰ Self
‰ Spouse
Group #:
‰ Child
)
Policy no.:
‰ Other
IN CASE OF EMERGENCY
Name of emergency contact person:
Relationship to
patient:
Home phone:
Other phone:
(
(
)
)
CONSENT INFORMATION
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to
Suwanee Family Dentistry, PC. I understand that I am financially responsible for all charges whether or not I have
insurance. I also authorize Suwanee Family Dentistry, PC or my insurance company to release any information required
to process my claim. I authorize the use of this signature on all my insurance submissions.
Patient/Guardian signature
Date
MINOR/CHILD Consent: I, being the parent or guardian of the patient listed above, do hereby request and authorize
the dental staff to perfom recommended services for my child, including but not limited to x-rays, the administration of
fluoride, local anesthetics, or nitrous oxide as deemed advisable by the doctor(s), whether or not I am present at the
actual appointment when the treatment is rendered.
Patient/Guardian signature
Date
Suwanee Family Dentistry, P.C.
MEDICAL HISTORY
PATIENT NAME _______________________________________________ Birth Date _____________________________________
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may
have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the
following questions.
Are you under a physician's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other
medications containing bisphosphonates?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Women: Are you
Pregnant/Trying to get pregnant?
Yes
No
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Yes
No
Yes
Yes
Yes
No
No
No
If yes, please explain:
If yes, please explain:
If yes, please explain:
If yes, please explain:
Taking oral contraceptives?
Yes
No
Nursing?
Yes
No
Are you allergic to any of the following?
Aspirin
Other
Penicillin
Codeine
Local Anesthetics
Acrylic
Metal
Latex
Sulfa drugs
If yes, please explain:
Do you have, or have you had, any of the following?
AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Have you been told to premedicate before dental work?
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No If( yes, please explain:
Comments:
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be
dangerous to my (or 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 ______________________
PATIENT INFORMATION:
NAME:
PATIENT ID:
CURRENT DENTIST INFORMATION:
NAME:
DATE OF LAST DENTAL VISIT:
_______________________________________________________________
ADDRESS:
__________________________
_______________________________________________________________
FREQUENCY OF DENTAL VISITS:
_______________________________________________________________
PHONE #:
__________________________
_______________________________________________________________
PRESENT SYMPTOMS – Please check all that apply
DO YOU SUFFER FROM ANY OF THE FOLLOWING:
Frequent heavy snoring
Nighttime teeth grinding or clenching
Significant daytime drowsiness
Jaw pain
Been told you stop breathing when sleeping
Facial pain
Morning headaches
Headaches
Gasping for air
Jaw clicking
Nighttime choking spells
Unable to open wide
Feeling unrefreshed in the morning
History of TMJ Disorder
Do you have a strong or severe gag reflex?
No
Yes
Do you have any allergies to:
Acrylic
No
Yes
Metals
No
Yes
Latex
No
Yes
Other: _______________________________
If you have tried and discontinued using a CPAP device, please list the reason why:
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
_____________________________________________________________________________________________
PATIENT SIGNATURE AND DATE: (HURJA000000012531458)
SIGNATURE:
DATE:
CONFIDENTIAL PATIENT INFORMATION
Have you ever had an evaluation at a Sleep Center? _____ Yes _____ No
If Yes:
Sleep Center Name _______________________________________
And Location
_______________________________________
Sleep Study Date
____________
CPAP Intolerance (Continuous Positive Airway Pressure device)
If you have attempted treatment with a CPAP device, but could not tolerate it please fill in this
section:
I could not tolerate the CPAP device due to:
mask leaks
I was unable to get the mask to fit properly
discomfort caused by the straps and headgear
disturbed or interrupted sleep caused by the presence of the device
noise from the device disturbing my sleep and/or bed partner's sleep
CPAP restricted movements during sleep
CPAP does not seem to be effective
pressure on the upper lip causing tooth related problems
a latex allergy
claustrophobic associations
an unconscious need to remove the CPAP apparatus at night
Other: _____________________________________________________________
Other Therapy Attempts
What other therapies have you had for breathing disorders?
(weight-loss attempts, smoking cessation for at least one month, surgeries, etc.)
Patient Signature__________________________ Date _________________________
ORAL APPLIANCE
INFORMED CONSENT FOR THE TREATMENT
OF SLEEP DISORDERED BREATHING WITH ORAL APPLIANCES
This form is called an “Informed Consent Form.” The purpose of this form is to verify that you have received
this information and have given your consent to procedure recommended to you. You should read this form
carefully and ask questions of your providers so that you understand the procedure before you decide
whether or not to give your consent. If you have questions, you are encouraged and expected to ask them
before you sign this form.
All procedures carry the risk of unsuccessful results, complications, injury or even death, from both known
and unforeseen causes, and no warranty or guarantee is made as to result or cure. You have the right to be
informed of:
▪ The nature of the procedure, including other care, treatment or medications;
▪ Potential benefits, risks or side effects of the procedure;
▪ The likelihood of achieving treatment goals;
▪ Reasonable alternatives and the relevant risks, benefits and side effects related to such alternatives,
including the possible results of not receiving care or treatment; and
▪ Any independent medical research or significant economic interests your provider may have related to the
performance of the proposed operation or procedure.
Except in cases of emergency, procedures are not performed until you have had the opportunity to receive
this information and have given your consent. You have the right to give or refuse consent to any proposed
procedure at any time prior to its performance.
You have been diagnosed as requiring treatment for sleep disordered breathing (snoring and/or obstructive
sleep apnea). Sleep disordered breathing occurs during sleep due to narrowing or total closure of the airway.
This condition may pose serious health risks since it disrupts normal sleep patterns, can reduce normal blood
oxygen levels and may result in excessive daytime sleepiness, irregular heartbeat, high blood pressure, heart
attack or stroke.
Oral Appliance Therapy
Oral appliances may be helpful in the treatment of sleep disordered breathing. Oral appliance therapy for
snoring/obstructive sleep apnea assists breathing by keeping the tongue and jaw in a forward position during
sleep. Oral appliance therapy has effectively treated many patients. However, there are no guarantees that it
will be effective for you, since every patient is different and there are many factors that influence the upper
airway during sleep. Furthermore, some people may not be able to tolerate the appliance in their mouth. It
is important to recognize that even when the therapy is effective, there may be a period of time before the
appliance functions maximally. During this time you may still experience the symptoms related to your sleep
disordered breathing. A post-adjustment polysomnogram (sleep study) is necessary to objectively assure
effective treatment. This must be obtained from your physician.
Side Effects and Complications of Oral Appliance Therapy
Published studies show that short term side effects of oral appliance use may include excessive salivation,
difficulty swallowing with the appliance in place, sore jaws, sore teeth, jaw joint pain, dry mouth, gum pain,
loosening of teeth and bite changes (how the upper and lower teeth come together). Oral appliances can
wear and break. The possibility that these or broken parts from them may be swallowed or aspirated exists.
There are also reports of dislodgment of ill-fitting dental restorations, such as fillings and/or crowns. Most of
these side effects are minor and resolve quickly on their own or with minor adjustment of the appliance.
Long-term complications include bite changes that may be permanent resulting from tooth movement or jaw
joint repositioning. These complications may or may not be fully reversible once appliance therapy is
ORAL APPLIANCE
discontinued. If not, restorative treatment or orthodontic intervention may be required for which you will be
responsible.
Follow-up visits with the provider of your oral appliance are mandatory to ensure proper fit and to allow an
examination of your mouth to assure a healthy condition. If unusual symptoms or discomfort occur outside
the scope of this consent, or if pain medication is required to control discomfort, it is recommended that you
cease using the appliance until you are evaluated further.
Upon using the device, patients may notice that after sleeping with an oral appliance they feel more
refreshed and alert. This is only subjective evidence of improvement and may be misleading. The only way to
accurately determine whether the appliance is keeping the oxygen level sufficiently high is to attend a follow
up consultation with your sleep doctor or your medical doctor. A follow up sleep test will be necessary to
determine effectiveness of your oral device.
Alternate Treatments for Sleep Disordered Breathing
Other accepted treatments for sleep disordered breathing include behavioral modifications, positive airway
pressure and various surgeries. It is your decision to have chosen oral appliance therapy to treat your sleep
disordered breathing and you are aware that it may not be completely effective for you and that you are
financially responsible for services rendered. It is your responsibility to report the occurrence of side effects
and to address any questions to the provider's office. Failure to treat sleep disordered breathing may
increase the likelihood of significant medical complications.
Consent
By signing below I, the patient, certify that I have read and fully understand this information concerning oral
appliance therapy for the treatment of sleep apnea. I have had the opportunity to discuss the foregoing
conditions and the information concerning the oral appliance with the provider and have had all questions
answered to my satisfaction.
I hereby authorize the taking of photographs and x-rays before, during and after treatment, and understand
that my diagnostic and treatment records may be used for the purposes of research, education or publication
in professional journals. While the appliance may be covered by my medical insurance, I accept any financial
responsibility for this therapy and authorize treatment and confirm that I have received a copy of this
consent form. I further understand that I will be responsible for the full cost of any repair or replacement
necessary for any lost or damaged appliance.
Your signature on this form indicates that:
▪ You have read and understand the information provided in this form;
▪ Your provider has adequately explained to you the procedure set forth above, along with the risks, benefits,
and the other information described above in this form;
▪ You have had a chance to ask your provider questions;
▪ You have received all of the information you desire concerning the procedure; and
▪ You authorize and consent to the performance of the procedure or treatment.
______________________________________
Patient Signature
___________________
Date
Suwanee Family Dentistry, PC
CONSENT FOR RELEASE OF MEDICAL AND BILLING INFORMATION
Patient Name: _____________________
Date of Birth:_______________ Date: ________________
Signature: ________________________________
Relationship to Patient: ______________________
I authorize Suwanee Family Dentistry, PC to release and disclose medical information and billing
information to Fusion Sleep, LLC.
I agree to the release of information from past, current, or future visits. I agree that a photocopy of this
authorization will be treated in the same manner as the original.
This authorization will remain in effect a maximum of one year from the date of signature and may be
cancelled by the patient in writing at any time. To cancel or revoke this authorization, the patient shall
forward a written notice to Suwanee Family Dentistry, PC at 2566 Lawrenceville Suwanee Rd. Suwanee,
GA 30024.
HIPAA STATEMENT
I understand that, under the Health Insurance Portability and Accountability Act of 1996 (HIPAA) and the
amendments to the HIPAA Regulations contained in the HIPAA Omnibus Final Rule enacted on January
29, 2013 and effective on March 26, 2013, 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 containing a more complete description of
the uses and disclosures of my health information. I understand that Suwanee Family Dentistry, PC has
the right to change its Notice of Privacy Practices from time to time and that I may contact Suwanee
Family Dentistry, PC at any time at the address above to obtain a current copy of the Notice of Privacy
Practices.
I understand that I may request in writing that Suwanee Family Dentistry, PC restricts how my private
information is used or disclosed to carry out treatment, payment or health care operations. I also
understand Suwanee Family Dentistry, PC is not required to agree to my requested restrictions, but if
Suwanee Family Dentistry, PC does agree then Suwanee Family Dentistry, PC is bound to abide by such
restrictions.
Signature of Patient/Guardian: ________________________________ Date: ___________________
PATIENT CONSENT
FORM
Consent for billing through Luna Dental Sleep Medicine Program
Consent for Use and Disclosure for Protected Health Information
I understand that as part of my health care, FusionSleep (Luna Dental Sleep Medicine program) originates and maintains paper
and/or electronic records describing my health history, symptoms, examination and test results, diagnoses, treatment and any
plans for future care or treatment (my protected health information or “PHI”). I understand that this information serves as:

A basis for planning my care and treatment,

A means of communication among the health professionals who contribute to my care,
A source of information for applying my diagnosis and therapy information to my bill,

A means by which a third-party-payer can verify that services billed were actually provided,

A tool for routine health care operations such as assessing quality and reviewing the
competence of health care professionals.
I authorize FusionSleep to release my PHI (including copies of records) needed for my treatment, for payment of the services
provided to me, and for health care operations such as quality assurance review or the provision of care after
discharge.
I have the right to review Fusion Sleep's Notice of Privacy Practices prior to signing this consent. FusionSleep reserves
the right to revise the Notice of Privacy Practices as well as the Patient Rights and Responsibilities pamphlet at any
time. A revised Notice of Privacy Practices may be obtained by visiting the Privacy & Security link on the FusionSleep
website or by forwarding a written request. This consent may be revoked at any time in writing by sending a written
notice of revocation. All correspondences should be sent to the address below.
FusionSleep – Medical Records
4245 Johns Creek Parkway, Suite A
Suwanee, Georgia 30024
Consent for Medical Treatment
I am asking for and consent to the delivery of the care by FusionSleep, including all necessary diagnostic tests,
examinations and medical treatments as the clinician prescribes. No one has given me a promise or guarantee about
how these examinations and treatments will affect me or my condition.
I have been fully informed about the details of the recommended treatment and alternatives, and agree to accept the treatment
as recommended by the provider. I further understand that individual reactions to treatment cannot be predicted, and that if I
experience any unanticipated reactions during or following any treatment, I agree to report them to the provider as soon as
possible. I have been informed that the success of the recommended treatment depends upon my cooperation in keeping
scheduled appointments, following home care instructions, and reporting to the provider any change in my health status as soon
as possible.
I understand that I have the right to see a physician, if I so choose, prior to any prescription drug or device order being
carried out by a physician assistant. I have discussed all of the above with the doctor, and all my questions have been answered
to my satisfaction. Following the explanation, the discussion, and the answers to my questions, I authorize the doctor to
complete the treatment as described.
Consent to Payment
I understand that payment for services provided are due at the time services are rendered. FusionSleep accepts payments in
the forms of cash, check, debit, and the following credit cards: Visa®, MasterCard®, American Express® and Discover®.
As a courtesy, FusionSleep may file insurance claims with my insurance carrier. I request that payment of benefits be made on
my behalf to Fusion Sleep, LLC. I authorize the release of medical information to my insurance carrier if it is needed to
determine benefits payable.
I understand that my health insurance plan may pay less than the actual bill for services rendered, and that I will be responsible
for payment of all services rendered. Further I am responsible for providing complete insurance information to FusionSleep for
accurate filing of claims. Reduction or rejection of my claim by my insurance company does not relieve the financial obligation I
have incurred to FusionSleep.
Additionally, I understand that some services that may be provided by FusionSleep will be billed separately for the office visit
and may require a separate co-payment be applied to my co-insurance/deductible. It is my responsibility to contact my
insurance company to verify my benefits. I acknowledge that I will be responsible for all fees not paid by my insurance
company.
PATIENT CONSENT
FORM
For Medicare or Medicaid, I hereby assign to Fusion Sleep or its affiliate payment of benefits due to me under Title XVIII
(Medicare) and XIX (Medicaid) of the Social Security Act for services provided by Fusion Sleep or its affiliates, including
physician services. I certify that the information given by me in applying for payment under Medicare or Medicaid is
correct. I authorize any holder of medical or other information about me to release to Medicare, Medicaid, and their
respective agents any information needed to determine these benefits or benefits for related services.
In the event that I fail to make payments for services rendered, I understand that my account may be turned over to a
collection
agency. I will be responsible for the payment of any collection agency's fees that may be incurred in the collection of any
outstanding balance.
Personal Valuables
FusionSleep takes all reasonable precautions to protect any patient property within the FusionSleep facilities, but
cannot be held liable for any valuables lost or damaged. I accept full responsibility for any valuables that I bring into the
FusionSleep facilities and I agree to fully indemnify and hold harmless FusionSleep for any loss, damage or destruction of my
belongings.
Medication and Discharge Policy
I have been made aware and given the opportunity to obtain a copy of the FusionSleep Medication policy.
I understand that the following are some causes for immediate dismissal from FusionSleep:




Obtaining a controlled substance medication from any other medical office, hospital, or urgent care while
under our care without notifying Fusion Sleep.
Altering or forging of a prescription which is a felony and will be reported.
GA Code 16-13-43: " ... and anyone violating this code will be guilty of a felony, and if convicted, can be
imprisoned for up to 8 years and/or fined up to $50,000'Lack of effort to comply with treatment
Disrespectful or inappropriate behavior
I understand that in the event that I refuse to sign this consent, FusionSleep may decline to provide services
Patient Name:
Date of Birth:
Signature of Patient:
Date:
Patient is unable to sign because she/he is a minor, _ years of
age.
Signature of Legally Authorized Representative:
Date:
Signature of Witness:
Date:
For office use only
Consent refused by patient
Signature of FusionSleep Employee:
Employee Printed Name:
Date: