Patient Information. Name Gender [ ]Male [ ]Female Last First Mi. SSN - - Married [ ]Yes [ ] No. Work phone: ( ) - - Address: City State Zip code

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Clare Underwood
5 years ago
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1 Patient Infrmatin We are pleased t welcme yu t ur ffice. Please take a mment t cmplete this frm as best yu can. If yu have any questins we ll be glad t help yu. Name Gender [ ]Male [ ]Female Last First Mi Birthdate / / SSN - - Married [ ]Yes [ ] N Cntact infrmatin: Hme phne: ( ) - - Wrk phne: ( ) - - Cell phne: ( ) Address: City State Zip cde Preferred cntact methd: Student Status if dependent ver 19: [ ] Hme [ ] Cell [ ] Wrk [ ] [ ] Nnstudent [ ] Part time [ ] Full time Hw did yu hear abut us? Occupatin: Insurance Infrmatin: Emplyer: Insurance cmpany: Subscriber s Emplyer: Subscriber ID: Grup number: Grup name: Subscriber s SSN: Subscriber s birthdate: / / Yur relatinship t subscriber: [ ] Self [ ] Spuse [ ] Child Secndary Insurance: Insurance cmpany: Subscriber s Emplyer: Subscriber ID: Grup number: Grup name: Subscriber s SSN: Subscriber s birthdate: / / Yur relatinship t subscriber: [ ] Self [ ] Spuse [ ] Child

2 Financial Plicy Name: (Last) (First) (MI) PAYMENT PLEASE CHECK ONE PAYMENT OPTION OPTION 1: Payment in full at each appintment (self-pay r ut f netwrk insurance). OPTION 2: Cpayment at each appintment f estimated amunt nt cvered by insurance. PAYMENT ARRANGEMENTS ARE REQUESTED AT THE TIME OF YOUR VISIT In an effrt t prvide yu with flexible payment arrangements, we have expanded ur payment methds. Our ffice is fully apprved and is an accredited user f the Visa and MasterCard Health Care Prgram which will enable yu t use yur Visa and MasterCard t autmatically cver amunts nt paid by yur insurance. Yu may als chse a cmfrtable amunt t be autmatically billed t yu Visa r MasterCard n a mnthly basis. PLEASE CHECK ONE PAYMENT METHOD METHOD 1: Payment at time f service by cash, check, credit card, r CareCredit METHOD 2: Payment plan with autmatic mnthly billing t yur Visa r MasterCard METHOD 3: Guarantee any amunt nt cvered by insurance with Visa r MasterCard n file Initial: AUTHORIZATION OF INSURANCE Initial: I hereby authrize payment directly t the dental ffice f Mindful Dental f the Insurance benefits therwise payable t me. BROKEN APPOINTMENTS Initial: I am aware that a $50 fee is charged when I, r a member f the family, des nt attend a dental appintment and des nt give the ffice a 24 hur ntice f a cancellatin. I have read and understand the financial plicy at Mindful Dental. Signature _ Date

3 Current Dental Health D any f the fllwing prblems apply t yu? [ ] Sensitivity [ ] Tth pain r discmfrt when chewing [ ] Headaches, ear aches, neck pain [ ] Muth ulcers r cld sres [ ] Jaw jint pain [ ] Brken tth r fillings [ ] Grinding r clenching teeth [ ] Bleeding, swllen r irritated gums [ ] Lse, tipped r shifted teeth Have yu had any f the fllwing? [ ] Dentures [ ] Partial dentures [ ] Braces [ ] Gum treatments [ ] Implants [ ] Required t take antibitics prir t dental treatment D yu smke r use chewing tbacc? [ ] yes [ ] n Hw much? Fr hw lng? I wuld like t learn mre abut: [ ] Replacing missing teeth [ ] Making my teeth whiter [ ] Making my teeth straighter [ ] Clsing spaces between my teeth [ ] Repairing chipped teeth [ ] Replacing ld crwns that dn t match Please tell us when: Yur last cleaning was: Yur last set f cmplete x-rays: What is the mst imprtant thing t yu abut yur future smile and dental health? What is the mst imprtant thing t yu abut yur dental visit tday?

4 Medical Histry Althugh dental persnnel primarily treat the area in and arund yur muth, yur muth is a part f yur entire bdy. Health prblems that yu may have, r medicatin that yu may be taking, culd have an imprtant interrelatinship with the dentistry yu will receive. Thank yu fr answering the fllwing questins. Are yu under a physician s care nw? [ ] yes [ ] n Name and Number: Have yu ever been hspitalized r had a majr peratin? [ ] yes [ ] n Please explain: Have yu ever had a serius head r neck injury? [ ] yes [ ] n Please explain: Are yu taking any medicatins, pills, r drugs? [ ] yes [ ] n Please explain: Have yu ever taken Fsamax, Bniva, Actnel, r any medicatins cntaining bisphsphnates? [ ] yes [ ] n Are yu n a special diet? [ ] yes [ ] n D yu use cntrlled substances? [ ] yes [ ] n Wmen: Are yu [ ] Pregnant/Trying t get pregnant? [ ] Taking ral cntraceptives? [ ] Nursing? Are yu allergic t any f the fllwing? [ ] Aspirin [ ] Penicillin [ ] Cdeine [ ] Lcal Anesthetics [ ]Acrylic [ ] Metal [ ] Latex [ ] Sulfa Drugs [ ] Other If ther, please explain: Please check if yu have, r have had, any f the fllwing: [ ] AIDS/HIV Psitive [ ] Alzheimer s [ ] Anaphylaxis [ ] Anemia [ ] Angina [ ] Arthritis/Gut [ ] Artificial Health Valve [ ] Artificial Jint [ ] Asthma [ ] Bld [ ] Breathing Prblem [ ] Bruise Easily [ ] Cancer [ ] Chemtherapy [ ] Chest Pains [ ] Cld Sres/ Fever Blisters [ ] Cngenital Heart Disrder [ ] Cnvulsins [ ] Crtisne Medicine [ ] Diabetes [ ] Drug Addictin [ ] Dry muth [ ] Emphysema [ ] Epilepsy r Seizures [ ] Excessive Bleeding [ ] Fainting spells/ Dizziness [ ] Heart Attack/ Failure [ ] Heart Murmur [ ] Heart Pacemaker [ ] Heart Truble/ [ ] Hemphilia [ ] Hepatitis A [ ] Hepatitis B r C [ ] Herpes [ ] High Bld Pressure [ ] High Chlesterl [ ] Hives r Rash [ ] Hypglycemia [ ] Irregular Heartbeat [ ] Kidney Prblems [ ] Leukemia [ ] Liver [ ] Lw Bld Pressure [ ] Lung [ ] Mitral Valve Prlapse [ ] Osteprsis [ ] Pain in Jaw jints [ ] Parathyrid [ ] Psychiatric Care [ ] Radiatin Treatments [ ] Renal Dialysis [ ] Rheumatism [ ] Shingles [ ] Sickle Celle [ ] Sinus Truble [ ] Stmach/ Intestinal [ ] Strke [ ] Swelling f Limbs [ ] Thyrid [ ] Tnsillitis [ ] Tuberculsis [ ] Tumrs r Grwths [ ] Ulcers [ ] Venereal [ ] Yellw Jaundice [ ] Other serius illnesses nt listed abve, explain: Cmments: T the best f my knwledge, The questins n this frm have been accurately answered. I understand that prviding incrrect infrmatin can be dangerus t my (r patient s) health. It is my respnsibility t infrm the dental ffice f any changes in medical status. Signature f Patient, Parent, r Guardian Date

5 HIPAA CONSENT OF SERVICES Yur Health Infrmatin May Be Used... TO PROVIDE TREATMENT We will use yur HEALTH INFORMATION within ur ffice t prvide yu with the best dental care pssible. This may include administrative and clinical ffice prcedures designed t ptimize scheduling and crdinatin f care between hygienist, dental assistant, dentist, and business ffice staff. In additin, we may share yur health infrmatin with physicians, referring dentists, clinical and dental labs, pharmacies r ther health care persnnel prviding yu treatment. TO OBTAIN PAYMENT We may include yur health infrmatin with an invice used t cllect payment fr treatment yu receive in ur ffice. We may d this with insurance frms filed fr yu in the mail r sent electrnically. We will be sure t nly wrk with the cmpanies with similar cmmitment t the security f ur health infrmatin. TO CONDUCT HEALTH CAREOPERATIONS Yur health infrmatin may be used during perfrmance evaluatins f ur staff. Sme f ur best teaching pprtunities use clinical situatins experienced by patients receiving care at ur ffice. As a result, health infrmatin may be including in training prgrams. It is als pssible that health infrmatin will be disclsed during audits by insurance cmpanies r gvernment appinted agencies as part f their quality assurance and cmpliance reviews. Yur health infrmatin may be reviewed during the rutine prcess f certificatin, licensing r credentialing activities. IN PATIENT REMINDERS Because we believe regular care is very imprtant t yur ral and general health, we will remind yu f a scheduled appintment r that it is time fr yu t cntact us and make an appintment. Additinally, we may cntact yu t fllw up n yur care and infrm yu f treatment ptins r services that may be f interest t yu r yur family. These cmmunicatins are an imprtant part f ur philsphy f patterning with ur patients t be sure they receive the best preventive and restrative care mdern dentistry prvide. They may include pstcards, flding pstcards, letters, telephne reminders, r texting. PUBLIC HEALTH AND NATIONAL SECURITY We may require t disclse t Federal Officials r military authrities health infrmatin necessary t cmplete an investigatin related t public health infrmatin necessary t cmplete an investigatin related t public health r natinal security. Health infrmatin culd be imprtant when the gvernment believes that the public safety culd benefit when the infrmatin culd lead t the cntrl r preventin f an epidemic r the understanding f new side effects f a drug treatment r a medical device. FAMILY, FRIENDS, AND CARE GIVERS We may share yur health infrmatin with thse yu tell us will be helping yu with hme hygiene, treatment, medicatin, r payment. We will be sure t ask yur permissin first. If there is an emergency, where yu are unable t tell us what yu want, we will use ur very best judgement when sharing yur health infrmatin nly when it will be imprtant t thse participating in prviding yur care. CONSENT FOR SERVICES Patients wh carry dental insurance understand that all dental services furnished are charged directly t the patient and that he r she is persnally respnsible fr payment f all dental services. This ffice will help prepare the patient s insurance frms r assist in making cllectins frm insurance cmpanies and will credit any such cllectins t the patients accunt. Hwever, this dental ffice cannt render services n the assumptin that ur charges will be paid by an insurance cmpany. A late charge may apply t an unpaid balance exceeding 30 days. I understand that the fee estimate listed fr this dental care can nly be extended fr a perid f six mnths frm the date f the patient s examinatin. I grant permissin t yu r yur assignee, t telephne me at hme r at my wrk t discuss matters related t this frm. A service charge f 1 ½% per mnth (18% per annum) n the unpaid balance will be charged n all accunts exceeding 60 days, unless previusly written financial arrangements are satisfied. ANESTHETICS: Mst prcedures are perfrmed with a lcal anesthetic (cmmnly referred t as Nvcain and Zylccaine). In additin, sedative and pain medicatins can be used t help minimize anxiety and discmfrt. In rare instances, allergic reactins may ccur, s yu are requested t infrm ur ffice staff f any knwn allergies yu may have. Sme sedative r pain medicatin may cause drwsiness. Therefre, when these medicatins are used, yu wuld need t make arrangements fr transprtatin with anther persn t and frm the ffice. Nitrus Oxide Sedatin (laughing gas) is used as well.

6 INFORMED CONSENT AND AURTHORIZATION: I certify that I have read and understand this Infrmed Cnsent, which utlines the general treatment cnsideratins as well as the ptential prblems and cmplicatin f dental treatment. I understand that ptential cmplicatins and prblems may include, but are nt limited t, thse described in the treatment and discussed with me. I understand that during and fllwing the treatment, and in the future, cnditins may becme apparent that warrant additinal r alternative treatment pertinent t the success f cmprehensive treatment. Recgnizing the ptential prblems and risks f dental treatment, authrizatin is given fr dental treatment t be rendered by the dentist and ffice staff. I als apprve any mdificatin in design, materials, r care, if it is felt this is fr my best interests. Patient Signature Date

GUIDE TO THE PROFESSIONAL PRACTICE STANDARD

GUIDE TO THE PROFESSIONAL PRACTICE STANDARD Veterinarian-Client-Patient Relatinship (VCPR) Published: July 2016 Revised: April 2017; Nvember 2017 Intrductin The Cllege s Prfessinal Practice Standard: Veterinarian-Client-Patient