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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? ___ ___ 2. Have you ever been hospitalized for any surgical operation or illness? ___ ___ 3. Are you taking any medication (s) including non-prescription medicine? ___ ___ If yes, what medication (s) are you taking ?________________________________________ 4. Have you ever taken Fen-Phen/Redux? ___ ___ 5. Do you use tobacco/pipe/chew? ___ ___ 6. Do you use alcohol, cocaine and/or other drugs? ___ ___ 7. Are you wearing contact lenses? ___ ___ 8. Do you need antibiotic pre-medication prior to dental work? ___ ___ 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? ___ ___ WOMEN ONLY 11. Are you pregnant or think you may be pregnant? 12. Are you nursing? ___ ___ ___ ___ 13. Are you taking birth control pills/patch/or medication? ___ ___ 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:___________________________________________________________________________