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120 1ST AVE SW
LARGO, FL 33770
(727) 518-8349
PATIENT HEALTH HISTORY (ADULT)
Date:
Sex:
Legal Name:
Last Name
First Name
Male
Middle Initial
Birth Date:
Address:
Social Security Number:
Primary Phone:
City
State
Alternate Phone:
Minor
Single
Patient Employer:
Married
Divorced
Zip
Email:
Widowed
Separated
Occupation:
Spouse's Name:
SS Number:
Spouse's Employer:
Birth Date:
Primary Phone:
Occupation:
How did you hear about our office?:
IN CASE OF EMERGENCY CONTACT
Relationship:
Alternate:
Contact Name:
Primary Phone:
Who is responsible for this account?:
Insurance Company:
Member ID:
Subscriber:
Group ID:
DENTAL HISTORY
Reason for today's visit?
Former Dentist:
Last Exam:
X-Rays:
Please mark to indicate if you have had any of the following:
Bad Breath
Bleeding Gums
Blister on lips or mouth
Burning sensation on tongue
Chew on one side of mouth
Cigarette, pipe, or cigar smoking
Clicking or popping jaw
Dry mouth
Fingernail biting
Food collection between teeth
Foreign objects
Grinding teeth
Gums swollen or tender
Jaw pain or tiredness
Lip or cheek biting
Loose teeth or broken fillings
Mouth breathing
Mouth pain, brushing
Orthodontic treatment
Pain around ear
Periodontal treatment
Sensitivity to cold
Sensitivity to heat
Sensitivity to sweets
Sensitity when biting
Sores or growths in your mouth
How often do you floss?
How often do you brush?
OVER
Female
HEALTH HISTORY
Are you under a physician's care now?
Primary Care Doctor
Have you ever been hospitalized or had major operation?(List)
Have you ever had serious neck or head injury?
Do you use controlled substances?
Are you taking or ever taken PHEN-FEN or REDUX?
Have you ever taken FOSAMAX, BONIVA, ACTONEL, or bisphonates?
Special Diet?
Do you use tobacco?
Medications, Pills, or Drugs
Please list:
Women: Are you…..
Pregnant/Trying
Nursing
Taking oral contraceptives
ALLERGIES
Aspirin
Penicillin
Codeine
Acrylic
Sulfa Drugs
Metal
Latex
Other?
Do you have or have you had any of the following?
AIDS/HIV Positive
Cortisone Medicine
Hepatitis A
Rheumatic Fever
Alzheimer's Disease
Diabetes
Hepatitis B or C
Rheumatism
Anaphylaxis
Drug Addiction
Herpes
Scarlet Fever
Anemia
Easily Winded
High Blood Pressure
Shingles
Angina
Emphysema
High Cholesterol
Sickle Cell Disease
Arthritis/Gout
Epilepsy or Seizures
Hives or Rash
Sinus Trouble
Artificial Heart Valve
Excessive Bleeding
Hypoglycemia
Spinal Bifida
Artificial Joint
Excessive Thirst
Irregular Heartbeat
Stomach/Intestinal Disease
Asthma
Fainting Spells/Dizziness
Kidney Problems
Stroke
Blood Disease
Frequent Cough
Leukemia
Swelling of Limbs
Blood Transfusion
Frequent Diarrhea
Liver Disease
Thyroid Disease
Breathing Problems
Genital Herpes
Low Blood Pressure
Tonsillitis
Bruise Easily
Glaucoma
Mitral Valve Prolapse
Tuberculosis
Cancer
Hay Fever
Osteoporosis
Tumors or Growths
Chemotherapy
Heart Attack/Failure
Pain in Jaw Joints
Ulcers
Chest Pains
Heart Murmur
Parathyroid Disease
Venereal Disease
Cold Sores/Fever Blister
Heart Pacemaker
Psychiatric Care
Yellow Jaundice
Congenital Heart Disorder
Heart Trouble/Disease
Radiation Treatments
Contact Lenses
Convulsions
Hemophilia
Recent Weight Loss
Other:
Hemophilia
Renal Dialysis
x
Patient Signature
Date
Local Anesthetics
Pinellas Family Dental
120 1st Ave SW
Largo, FL 33770
(727) 518-8349 Phone
(727) 518-8339 Fax
www.dentalflorida.com
Informed Consent For General Dental Procedures
You the patient have the right to accept or reject dental treatment recommended by your dentist. Prior to
consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of
the recommended procedure, alternative treatments, or the option of no treatment.
Do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your
dentist and all your questions are answered. By consenting to treatment, you are acknowledging your
willingness to accept known risks and complications, no matter how slight the probability of occurrence.
As with all surgery, there are commonly known risks and potential complications associated with dental
treatment. No one can guarantee the success of the recommended treatment, or that you will not experience a
complication or less than optimal result. Even though many of these complications are rare, they can and do
occur occasionally.
Some of the more commonly know risks and complications of treatment include, but are not limited to the
following:
1. Pain, swelling, and discomfort after treatment.
2. Infections in need of medication, follow-up
procedures, or other treatment.
3. Temporary or on rare occasion permanent numbness, pain, tingling, or altered sensation of the lip, face,
chin, gums, and tongue along with possible loss of taste.
4. Damage to the adjacent teeth, restorations, or gums.
5. Possible deterioration of your condition which may result in tooth loss.
6. The need for replacement of restorations, implants, or other appliances in the future.
7. An altered bite in need of adjustment.
8. Possible injury to the jaw joint and related structures requiring follow-up care and treatment, or
consultation by a dental specialist.
9. A root tip, bone fragment, or piece of dental instrument may be left in your body, and may have to be
removed at a later time if symptoms develop.
10. Jaw Fracture
11. If upper teeth are treated, there is a chance of sinus infection or opening between the mouth and sinus
cavity resulting in infection or the need for further treatment.
12. Allergic reaction to anesthetic or medication.
13. Need to follow-up treatment, including surgery
It is very important that you provide your dentist with accurate information before, during, and after treatment.
It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre
and post treatment instructions, referrals to other dentist or specialists, and return for scheduled appointments.
If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.
Pinellas Family Dental
120 1st Ave SW
Largo, FL 33770
(727) 518-8349 Phone
(727) 518-8339 Fax
www.dentalflorida.com
Certain heart conditions may create a risk of serious or fatal complications. If you (or a minor patient) have a
heart condition or heart murmur, advise your dentist immediately so he/she can consult your physician if
necessary.
The patient is a part of the treatment team. In addition to complying with the instructions given to you by this
office, it is important to report any problems or complications you experience so they can be addressed by your
dentist.
If you are a woman on oral birth control medication, you must consider the fact that antibiotics might make oral
birth control less effective. Please consult with your physician before relying on oral birth control medication if
you dentist prescribes, or if you are taking antibiotics.
If you are contemplating having a tooth removed (extraction) or gum and bone surgery (periodontal surgery)
and are taking orally or IV or have taken orally or IV Fosamax (Alendronate) or Actonel (Risedronate) or
Boniva (Ibandronate) or Bonefos (Clodronate) or Aredia (Pamidronate) or Zometa (Zoledronic acid). Then this
area may not heal ever, resulting in non-healing exposed bone (osteonecrosis or recalcitrant non-healing bone
or osteochemonecrosis or ONJ). Please consult your physicians etc. prior to asking your dentist to remove
(extract) a tooth and or do gum and bone surgery (periodontal surgery).
In an effort to control the increasing costs of dental care, any claims or disputes against this office shall be
resolved by “binding arbitration.” By signing this agreement, the patient agrees with the office of Pinellas
Family Dental, that any dispute relating to dental or medical care services rendered for any condition, including
any services rendered prior to the date this agreement was signed, and any dispute arising out of the diagnosis,
treatment, or care of the patient, including the scope of this arbitration clause and the arbitrability of any claim
or dispute, against whenever made, (including to the full extent permitted by applicable law third parties who
are not signatories to this agreement [including associates]) shall be resolved by binding arbitration by the
National Arbitration Forum, under the Code of Procedure then in effect. The patient understands that the result
of this arbitration agreement is that claims, including malpractice claims he/she may have against the doctor,
cannot be brought as a lawsuit in court before a judge or jury, and agrees that all such claims will be resolved as
described in this section.
This form is intended to provide you with any overview of potential risks and complications. Do not sign this
form or agree to treatment until you have read, understood, and accepted each paragraph stated above. Please
discuss the potential benefits, risks, and complications of recommended treatment with your dentist. Be certain
all of your concerns have been addressed to your satisfaction by your dentist before commencing treatment.
_________________________________
_________________________________
Patient
Witness
Date
________________________________
Print Patient Name
Date
_________________________________
Parent/ Legal Guardian
Date
Pinellas Family Dental
120 1st Ave SW
Largo, FL 33770
(727) 518-8349 Phone
(727) 518-8339 Fax
www.dentalflorida.com
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND
DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY
OUR PRVACY PRACTICES COMPLY WITH OMNIBUS 2013 – EFFECTIVE 09/23/2013
Pinellas Family Dental is required by law to maintain the privacy of protected health information, to provide individuals with notice
of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a
breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is
in effect. This Notice takes effect 09/23/2013, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted
by applicable law, and to make new Notice provisions effective for all protected health information that we maintain. When we
make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at
our practice location, and we will provide copies of the new Notice upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this
Notice, please contact us using the information listed at the end of this Notice.
HOW WE MAY USE AND DICLOSE HEALTH INFORMATION ABOUT YOU
We may use and disclose your health information for different
purposes, including treatment, payment, and health care operations. For
each of these categories, we have provided a description and an
example. Some information, such as HIV-related information, genetic
information, alcohol and/or substance abuse records, and mental health
records may be entitled to special confidentiality protections under
applicable state or federal law. We will abide by these special
protections as they pertain to applicable cases involving these types of
records.
Treatment. We may use and disclose your health information for your
treatment. For example, we may disclose your health information to a
specialist providing treatment to you.
Payment. We may use and disclose your health information to obtain
reimbursement for the treatment and services you receive from us or
another entity involved with your care. Payment activities include
billing, collections, claims management, and determinations of
eligibility and coverage to obtain payment from you, an insurance
company, or another third party. For example, we may send claims to
your dental health plan containing certain health information.
Healthcare Operations. We may use and disclose your health
information in connection with our healthcare operations. For example,
healthcare operations include quality assessment and improvement
activities, conducting training programs, and licensing activities.
Individuals Involved in Your Care or Payment for Your Care. We
may disclose your health information to your family or friends or any
other individual identified by you when they are involved in your care
or in the payment for your care. Additionally, we may disclose
information about you to a patient representative. If a person has the
authority by law to make health care decisions for you, we will treat
that patient representative the same way we would treat you with
respect to your health information.
Disaster Relief. We may use or disclose your health information to
assist in disaster relief efforts.
Required by Law. We may use or disclose your health information
when we are required to do so by law.
Public Health Activities. We may disclose your health information for
public health activities, including disclosures to:
• Prevent or control disease, injury or disability
• Report child abuse or neglect;
•
•
•
•
Report reactions to medications or problems with products or
devices;
Notify a person of a recall, repair, or replacement of products
or devices;
Notify a person who may have been exposed to a disease or
condition; or
Notify the appropriate government authority if we believe a
patient has been the victim of abuse, neglect, or domestic
violence.
National Security. We may disclose to military authorities the health
information of Armed Forces personnel under certain circumstances.
We may disclose to authorized federal officials health information
required for lawful intelligence, counterintelligence, and other national
security activities. We may disclose to correctional institution or law
enforcement official having lawful custody the protected health
information of an inmate or patient.
Secretary of HHS. We will disclose your health information to the
Secretary of the U.S. Department of Health and Human Services when
required to investigate or determine compliance with HIPAA.
Worker’s Compensation. We may disclose your PHI to the extent
authorized by and to the extent necessary to comply with laws relating
to worker’s compensation or other similar programs established by law.
Law Enforcement. We may disclose your PHI for law enforcement
purposes as permitted by HIPAA, as required by law, or in response to
a subpoena or court order.
Health Oversight Activities. We may disclose your PHI to an
oversight agency for activities authorized by law. These oversight
activities include audits, investigations, inspections, and credentialing,
as necessary for licensure and for the government to monitor the health
care system, government programs, and compliance with civil rights
laws.
Judicial and Administrative Proceedings. If you are involved in a
lawsuit or a dispute, we may disclose your PHI in response to a court or
administrative order. We may also disclose health information about
you in response to a subpoena, discovery request, or other lawful
process instituted by someone else involved in the dispute,
Pinellas Family Dental
120 1st Ave SW
Largo, FL 33770
but only if efforts have been made, either by the requesting party or us,
to tell you about the request or to obtain an order protecting the
information requested.
Research. We may disclose your PHI to researchers when their
research has been approved by an institutional review board or privacy
board that has reviewed the research proposal and established protocols
to ensure the privacy of your information.
Coroners, Medical Examiners, and Funeral Directors. We may
release your PHI to a coroner or medical examiner. This may be
necessary, for example, to identify a deceased person or determine the
cause of death. We may also disclose PHI to funeral directors
consistent with applicable law to enable them to carry out their duties.
Fundraising. We may contact you to provide you with information
about our sponsored activities, including fundraising programs, as
permitted by applicable law. If you do not wish to receive such
information from us, you may opt out of receiving the communications.
Other Uses and Disclosures of PHI
Your authorization is required, with a few exceptions, for disclosure of
psychotherapy notes, use or disclosure of PHI for marketing, and for
the sale of PHI. We will also obtain your written authorization before
using or disclosing your PHI for purposes other than those provided for
in this Notice (or as otherwise permitted or required by law). You may
revoke an authorization in writing at any time. Upon receipt of the
written revocation, we will stop using or disclosing your PHI, except to
the extent that we have already taken action in reliance on the
authorization.
Your Health Information Rights
Access. You have the right to look at or get copies of your health
information, with limited exceptions. You must make the request in
writing. You may obtain a form to request access by using the contact
information listed at the end of this Notice. You may also request
access by sending us a letter to the address at the end of this Notice. If
you request information that we maintain on paper, we may provide
photocopies. If you request information that we maintain electronically,
you have the right to an electronic copy. We will use the form and
format you request if readily producible. We will charge you a
reasonable cost-based fee for the cost of supplies and labor of copying,
and for postage if you want copies mailed to you. Contact us using the
information listed at the end of this Notice for an explanation of our fee
structure. If you are denied a request for access, you have the right to
have the denial reviewed in accordance with the requirements of
applicable law.
Disclosure Accounting. With the exception of certain disclosures, you
have the right to receive an accounting of disclosures of your health
information in accordance with applicable laws and regulations. To
request an accounting of disclosures of your health information, you
must submit your request in writing to the Privacy
Official. If you request this accounting more than once in a 12- month
period, we may charge you a reasonable, cost-based fee for responding
to the additional requests.
(727) 518-8349 Phone
(727) 518-8339 Fax
www.dentalflorida.com
Right to Request a Restriction. You have the right to request
additional restrictions on our use or disclosure of your PHI by
submitting a written request to the Privacy Official. Your written
request must include (1) what information you want to limit, (2)
whether you want to limit our use, disclosure or both, and (3) to whom
you want the limits to apply. We are not required to agree to your
request except in the case where the disclosure is to a health plan for
purposes of carrying out payment or health care operations, and the
information pertains solely to a health care item or service for which
you, or a person on your behalf (other than the health plan), has paid
our practice in full.
Alternative Communication. You have the right to request that we
communicate with you about your health information by alternative
means or at alternative locations. You must make your request in
writing. Your request must specify the alternative means or location,
and provide satisfactory explanation of how payments will be handled
under the alternative means or location you request. We will
accommodate all reasonable requests. However, if we are unable to
contact you using the ways or locations you have requested we may
contact you using the information we have.
Amendment. You have the right to request that we amend your health
information. Your request must be in writing, and it must explain why
the information should be amended. We may deny your request under
certain circumstances. If we agree to your request, we will amend your
record(s) and notify you of such. If we deny your request for an
amendment, we will provide you with a written explanation of why we
denied it and explain your rights.
Right to Notification of a Breach. You will receive notifications of
breaches of your unsecured protected health information as required by
law.
Electronic Notice. You may receive a paper copy of this Notice upon
request, even if you have agreed to receive this Notice electronically on
our Web site or by electronic mail (e-mail).
Questions and Complaints
If you want more information about our privacy practices or have
questions or concerns, please contact us. If you are concerned that we
may have violated your privacy rights, or if you disagree with a
decision we made about access to your health information or in
response to a request you made to amend or restrict the use or
disclosure of your health information or to have us communicate with
you by alternative means or at alternative locations, you may complain
to us using the contact information listed at the end of this Notice. You
also may submit a written complaint to the U.S. Department of Health
and Human Services. We will provide you with the address to file your
complaint with the U.S. Department of Health and Human Services
upon request
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint
with us or with the U.S. Department of Health and Human Services.
Telephone: (727) 518-8349 Fax: (727)518-8339
Address: 120 1st Ave SW, Largo, FL 33770
E-mail: [email protected]
Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the prior written
approval of the American Dental Association.
© 2010, 2013 American Dental Association. All Rights Reserved.
Pinellas Family Dental
120 1st Ave SW
Largo, FL 33770
(727) 518-8349 Phone
(727) 518-8339 Fax
www.dentalflorida.com
Acknowledgement of Receipt of HIPAA Notice of Privacy Practices
I have had full opportunity to read and consider the contents of Pinellas Family Dental’s HIPAA Notice
of Privacy Practices. I am aware that I may request a copy of this notice at anytime. I understand that,
by signing this consent form, I am giving my consent to use and disclose my protected health
information to carry out treatment, payment activities, and health care operations.
________________________________
Signature
_________________
Date
I give Pinellas Family Dental permission to speak to the following people in regards to my treatment,
care, account, and appointments. I may update the people listed at any time.
Name:_________________________ Relationship:_________________ Phone:__________________
Name:_________________________ Relationship:_________________ Phone:__________________
Name:_________________________ Relationship:_________________ Phone:__________________
________________________________
Signature
_________________
Date
Pinellas Family Dental
120 1ST AVENUE SW | LARGO FL, 33770 | (727) 518-8349
Written Financial Policy
Thank you for choosing Pinellas Family Dental. Our primary mission is to deliver the best and most comprehensive
dental care available. An important part of the mission is making the cost of optimal care as easy and manageable
for our patients as possible by offering several payment options.
Payment Options:
You can choose from:
- Cash, Check, Visa®, MasterCard®, American Express® or Discover Card®
We offer a 5% courtesy accounting adjustment to patients who pay for their treatment with Cash, Check
or Credit Card prior to start of treatment for treatment plans of $500 or more. (Not to be combined with
other discounts or savings plans)
- Convenient Monthly Payment Options¹ from CareCredit Healthcare Credit Card and Lending Club
Please note:
Pinellas Family Dental requires payment at the beginning of your treatment. If you choose to discontinue care before
treatment is complete, you will receive a refund less the cost of care received.
For plans requiring more than 2 appointments, alternative payment arrangements may be provided.
For patients with dental insurance we are happy to work with your carrier to maximize your benefit and directly bill
them for reimbursement for your treatment. If the amount paid by your insurance company differs from the amount
estimated, the unpaid portion is the responsibility of the patient. Our assistance in filing of your insurance claim is in
no way an acceptance of liability for unpaid claims. Any changes in your insurance policy or coverage must be
brought to our attention prior to your dental visit. In addition, we cannot be responsible for the accuracy of the
information given to us by your insurance company. If you have a question regarding your benefits, please contact
your insurance company.
By signing below, you hereby authorize responsible parties to pay directly to Pinellas Family Dental, any
insurance benefits due to you for services rendered. You agree to be responsible for any balance
remaining on the account after insurance payment. In the event that the insurance payment is not received
within 45 days of the initial billing date, you will be responsible for payment in full of the balance due on
your account. You hereby authorize said assignee to release all information and duplicate radiographs as
necessary to secure payment. (A photocopy of this agreement is considered as valid as the original)
Pinellas Family Dental charges $35.00 for returned checks.
There will be a charge for appointments canceled without 24 hours notice. This charge will be according to your fee
schedule.
In the event that your account becomes delinquent you will be responsible for all court cost, attorney fees, and any
additional fees necessary to collect the debt.
If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or
need.
Patient, Parent or Guardian Signature
Patient Name (Please Print)
¹Subject to credit approval
Date