Download ALL_NEW_PATIENT_FORMS

First Name:
Last Name:
Preferred Name:
Middle Initial:
Sex:
Male
Mailing Address:
Female
City, State, Zip:
Home Phone:
Work Phone:
(ext)
Cell Phone:
Please check which phone numbers are the most convenient for use.
Birth Date:
Age:
Social Security:
-
-
Email Address:
Please let us know if you would like email updates on your appointments.
Responsible Party (if different from that patient):
Mailing Address:
City, State, Zip:
Home Phone:
Work Phone:
Birth Date:
(ext)
Cell Phone:
Email Address:
PRIMARY DENTAL INSURANCE INFORMATION
Name of Insured:
Relationship to Insured:
Insured Birth Date:
Self
Insured Social Security:
Spouse
-
Insured ID #:
Group #:
Insured Employer:
Insurance Company:
Insurance Phone #:
Address:
DENTAL HISTORY
City, State, Zip:
Child
Other
-
How did you hear about us? (if referred, please give the name)
Date of last visit to a dentist:
Reason for visit
•
Date of last teeth cleaning:
•
Do you have a history of Periodontal Surgery?
•
What is the reason you left your last dentist?
Moved
X-Rays:
Dentist retired
Unsatisfied
Other
•
What kind of toothbrush do you use? _______________________________________________
•
What is your oral hygiene: (circle all that applies)
Brushing twice a day
flossing once a day
Smile Survey: (circle all that applies)
I want whiter teeth
grinding/clenching
My teeth are too small/large
Too much gum showing when I smile
proxybrush
oral rinse
frequent headaches
unsatisfied with smile
want straighter teeth
There is hesitation to smile
too much space between teeth
I don’t know the options to enhance my smile
PERIODONTAL RISK ASSESSMENT QUESTIONAIRE
Do you now or have ever used the following:
# per day
how many years used
year quit
__ Cigarette ________
__________________ ________
__ Cigar
________
_________________
________
__ Pipe
________
_________________ _________
__ Chewing ________
_________________
_________
If you are a patient who has diabetes:
Is your diabetes under control? YES NO
Are you prone to diabetic complications? YES NO
How do you monitor your blood sugar? ___________________________
Who is your physician for diabetes? ______________________________
If you are NOT a patient who has diabetes:
Any family history of diabetes? YES NO
Have you had any of these warning signs of diabetes?
-Frequent urination
-excessive thirst
-excessive hunger
-Unexplained weight loss
-weakness and fatigue
-slow healing cuts
Do you have any risk factors for heart disease or stroke?
-Family history of heart disease
-tobacco use
-obesity
-High cholesterol
-high blood pressure
If you have any of these other risk factors it is especially important to keep your gums as healthy as possible
Is there an immediate family member(s) who currently has or had gum problems in the past? YES
NO
Do you have a heart murmur or artificial joint? YES
NO
If so, does your physician recommend antibiotics prior to dental visits? YES
NO
If you answered yes, it is especially important to always keep your gums as healthy and inflammation-free as possible to reduce
the chance of bacterial infection originating from the mouth.
The following can adversely affect your gums. Please check all that apply:
-Pregnant
-nursing
-menopause -taking birth control pills
-infrequent care during pregnancies
FEMALES:
Do you take any of the following?
-Estrogen Replacement Therapy/Hormone Replacement Therapy (such as Prempro, Premarin, Premphase, Fosamax, Actonel,
Evista, Forteo, etc)
Other: ________________________________________
Are you under a lot of stress? YES
NO
Do you find it difficult to maintain a well-balanced diet?
YES
NO
Have you noticed any of the following signs of gum disease?
-Bleeding gums during tooth brushing -pus between teeth and gums
-red, swollen or tender gums
-Loose or separating teeth
-gums that have pulled away from the teeth
-food catching between teeth
-Persistent bad breath
-change in the way your teeth fit together
Is it important to keep your teeth for as long as possible?
YES
NOT REALLY
If you have missing teeth, what has prevented you from replacing them? _______________________________
_
•
•
•
•
•
•
•
Answer all questions circling Yes (Y) or No (N)
Are you in good health?
Has there been any change in your general health in the past year?
Date of last physical exam?
Are you now under a physician’s care for a particular problem?
N
Have you ever had any serious illness, operations, or hospitalization? If so, describe
Y
Y
N
N
Y
Y
N
DO YOU HAVE OR HAVE YOU EVER HAD:
• Rheumatic Fever or Rheumatic Heart Disease?
Y
N
• Congenital Heart Disease?
Y
N
• Cardiovascular Disease (Heart Attack, Heart Trouble, Heart Murmur, Coronary Artery Disease, Angina, High
Blood Pressure, Stroke, Palpitations, Heart Surgery, Pacemaker)?
Y
N
• Lung Disease (Asthma, Emphysema, COPD, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, Shortness of
Breath, Chest Pain, Severe Coughing)?
Y
N
• Seizures, Convulsions, Epilepsy, Fainting or Dizziness?
Y
N
•
Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion?
•
•
•
•
•
•
•
•
•
•
•
•
Y
N
Do you bruise easily?
Y
N
Liver Disease?
Y
N
Kidney Disease?
Y
N
Diabetes?
Y
N
Thyroid Disease (Goiter)
Y
N
Arthritis?
Y
N
Stomach Ulcers or Colitis?
Y
N
Glaucoma?
Y
N
Osteoporosis?
Y
N
Implants placed anywhere on your body (Heart Valve, Pacemaker, Hip, Knee)?
Y
N
Radiation (x-ray) treatment for Cancer?
Y
N
Clicking or Popping of jaw joint, pain near ear, difficulty near ear, difficulty opening mouth, grind or clench
teeth?
Y
N
• Sinus or Nasal problems?
Y
N
• Any disease, drug or transplant operation that has depressed your immune system?
Y
N
• ARE YOU USING ANY OF THE FOLLOWING:
• Antibiotics?
Y
N
• Anticoagulants (blood thinners)
Y
N
• Aspirin or drugs such as Motrin, Aleve, Ibuprofen?
Y
N
• High Blood Pressure Medication?
Y
N
• Steroids?
Y
N
• Tranquilizers?
Y
N
• Insulin, or Oral Anti-diabetic drugs?
Y
N
• Digitalis, Inderal, Nitroglycerin or other heart drug?
Y
N
• Are you taking or have you ever taken Bisphosphonates for osteoporosis, multiple myeloma or other cancers
(Reclast, Fosamax, Actonel, Boniva, Aredia, Zometa)?
Y
N
• Have you ever been advised NOT to take medication?
Y
N
• Please list any and all medications taken, including prescription medications, diet drugs, over-the-counter
medications, herbal or holistic remedies, vitamins or minerals:
•
ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ADVERSE REACTION TO:
• Local anesthesia?
Y
N
• Penicillin or other antibiotics? Y
N
• Sedatives, Barbiturates?
Y
N
• Aspirin or Ibuprofen?
Y
N
•
•
•
•
•
•
•
•
• Codeine or other pain killers? Y
N
• Latex or Rubber Products?
Y
N
• Metal of any kind?
Y
N
• Chemicals or jewelry?
Y
N
• Food products?
Y
N
• Other allergies or reactions? Please List
Do you smoke or chew tobacco?
Y
N
• How many per day?
Is there any past history of Alcohol or Chemical Dependency or Emotional Disorder that may affect the care
we provide you?
Y
N
Have you had any serious problems associated with any previous dental treatment?
Y
N
Have you or an immediate family member had any problem associated with intravenous anesthesia? Y
N
Do you have any other disease, condition or problem not listed above that you think the doctor should know
about?
Y
N
Do you wish to talk to the doctor privately about anything?
Y
N
Have you ever had a bone density scan?
Y
N
FOR WOMEN ONLY
• Are you Pregnant, or is there any chance you might be pregnant?
Y
N
• Are you nursing?
Y
N
• If you are using Oral Contraceptives, it is important that you understand that antibiotics (and some
other medications) may interfere with the effectiveness of the oral contraceptives. Please consult with
your physician for further guidance.
I understand the importance of truthful and complete Heath History to assist my dentist in providing the best care
possible. I have had the opportunity to discuss my Health History with my dentist.
Date:
Signature
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION AND OFFICE POLICIES
PLEASE READ THE FOLLOWING CAREFULLY:
PURPOSE OF CONSENT: By signing this form, you will consent to our use and disclosure of your protected health
information to carry out treatment, payment activities and healthcare operations.
NOTICE OF PRIVACY PRACTICES: You have the right to read our Notice of Privacy Practices before you decide
whether to sign this Consent. Our notice provides a description of our treatment, payment activities, and healthcare
operations, of the uses and disclosures we may make of your protected health information, and of other important matters
about your protected health information. A copy of our Notice can be found at the front desk when asked. We reserve the
right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices,
we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of
your protected health information that we maintain.
If you decide to pay for your treatment in full on the date of service and do not want your insurance to be billed, you have
the right to request not to disclose treatment information for this service to a health plan.
If applicable, a patient has the right to an Electronic copy of their records if they prefer.
YOU MAY OBTAIN A COPY OF OUR Notice of Privacy Practices, INCLUDING ANY REVISIONS OF OUR
NOTICE, AT ANY TIME, BY CONTACTING US.
RIGHT TO REVOKE: You will have the right to revoke this consent at any time by giving us written notice of your
revocation. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent
before we received your revocation, and that WE MAY DECLINE TO TREAT YOU OR TO CONTINUE
TREATING YOU if you revoke this consent.
Authorization and Release of Records
I authorize Larsen Family Dentistry to release any information, including the diagnosis and the records of any
treatment or examination rendered to me or my child during the period of such dental care, to third party payers and/or
health practitioners. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I agree
to allow Larsen Family Dentistry to leave messages concerning my appointments and/or results on my answering machine
or with family members.
Payment Policy
•
Payment is expected at the time the service is rendered. We will accept
Cash
Personal checks
DiscoverCard
The following Credit Cards:
Visa
MasterCard
•
Non-insured patients are expected to make payment in full on the day the service is rendered, unless definite
arrangements have been made with our office manager PRIOR TO TREATMENT.
•
Patients with dental insurance are expected to pay the portion of the total fee not covered by their insurance on
the day of service. The “Patient Portion” is ONLY an estimated dollar amount.
AS A COURTESY, our office will file your claim with your insurance company, and initiate correspondence with the
purpose of getting you the maximum coverage your insurance will allow; however, if we do not receive payment from
your insurance company within 60 days, the payment becomes your responsibility.
•
It is the PATIENT’S responsibility to know and understand his/her insurance coverage. Larsen Family Dentistry
will be happy to give you the number of your insurance company to contact them with further questions.
•
The patient is ALWAYS responsible for seeing that the ENTIRE FEE is paid in full.
•
If payment is not taken care of by the insurance or the patient within 90 days, there will be a fee added to the
account, and the account will be sent to Collections.
Reminder Policy
• AS A COURTESY, Larsen Family Dentistry gives reminders of the patients’ appointments via mail and phone.
However, it is the patient’s responsibility to remember their appointments and be on time. It is not the
responsibility of the office if the patient does not receive the reminders and forgets his/her appointment, which
will result in a failed appointment fee.
Cancellation Policy
To achieve the highest level of patient care and time management, our office requires appointment changes to occur
within the office hours (7:00am to 3:00pm) the day before (24 hours) the appointment date. Failure to do so will result in a
$50.00 failed appointment fee.
AS A PATIENT/RESPONSIBLE PARTY AT LARSEN FAMILY DENTISTRY I UNDERSTAND AND AGREE TO
THE ABOVE POLICIES
PRINT _____________________________________________________, have had full opportunity to read and consider
the contents of this Consent form and your Notice of Privacy Practices. I understand that by signing this Consent form, I
am giving my consent to your use and disclosure of my protected health information to carry our treatment, payment
activities and health care operations.
SIGNATURE
____________________________________________________________DATE_______________________________
IF SIGNED BY REPRESENTATIVE OR ON BEHALF OF THE PATIENT, COMPLETE THE FOLLOWING:
NAME _________________________________________RELATIONSHIP TO PATIENT
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.