1 - Teeth Whitening



Although dental personnel treat the area in and around your mouth, your mouth is a part of your entire body. Health conditions or problems that you may have or had, or medications that you may be taking, could have an important interrelationship with the treatment you will receive. Thank you for answering the following questions.AllergiesAcrylicsY NAnaphalaxisY NLatexY NLocal AnestheticsY NPenicillinY NMetalY NSulphaY NOtherY NList other known allergies:___________________________________________________________________________________________________________________________________________________________CardiovascularArtificial Heart ValveY NCoronary Artery DiseaseY NChest Pain or AnginaY NCongestive Heart FailureY NHeart AttackY NHeart MurmurY NHigh Blood PressureY NHigh CholesterolY NIrregular Heart BeatY NLow Blood PressureY NMitral Valve ProlapseY NPacemakerY NTachycardia Y NEndocrineDiabetesY NGoutY NHormonal ChangeY NThyroid problemsY NEyes, Ears, Nose and ThroatChange in HearingY NChange in VisionY NDysphagiaY NEar PainY NGlaucomaY NHay FeverY NNasal ObstructionY NNose BleedingY NSinus ProblemsY NTonsillectomyY NTinnitusY NGastrointestinalAcid RefluxY NGERDY NSoft or Special DietY NUlcersY NGenitourinaryFrequent UrinationY NKidney diseaseY NNocturia Y NGeneralCurrent weight: _________lbsHeight: _______ ft ______inCancerY NFatigue/TiredY NGeneral WeaknessY NHeadachesY NHIV/AIDSY NKnee/hip replacementY NLiver problemsY NRecent Trauma or InjuryY NRheumatic FeverY NRadiation TreatmentY NWeight ChangeY NHematologicalBleeding problemsY NHepatitis Y NOralBleeding gumsY NDry mouthY NJaw problems (TMJ)?Y N Clicking?Y N Pain?Y N Difficulty swallowing?Y N Difficulty chewing?Y NOrthodontics/InvisalignY NPeriodontal DiseaseY NTeeth clenchingY NTeeth grindingY NTooth painY NWisdom teeth extractionY NDo you wear removable teeth?Y NDo you take or need antibiotics before dental procedures?Y NMusculoskeletalBack PainY NFibromyalgiaY NJoint PainY NNeurologicalAlzheimer’s DiseaseY NDizzinessY NFaintingY NMemory LossY NMultiple Sclerosis (MS)Y NMuscle WeaknessY NSeizuresY NStrokeY NTingling/NumbnessY NTrigeminal NeuralgiaY NTremorY NPsychiatricADD/ADHDY NAnxietyY NChemical DependencyY NDepressionY NEating disordersY NExcessive StressY NMemory problemsY NRespiratoryAsthmaY NBronchitisY NBreathing problemsY NChest PressureY NCongestionY NDyspnea(shortness of breath)Y NEmphysemaY NOrthopneaY NPneumoniaY NPulmonary EmbolismY NTuberculosisY NSleepDaytime SleepinessY NMorning headachesY NObstructive Sleep ApneaY NDo you use a CPAP?Y N How often? __________________Has anyone told you that you snore?Y NSocial HistoryDo you smoke? N Y _____ packs a dayDo you use smokeless tobacco? Y NDo you consume alcoholic beverages? _____Drinks per day/week/monthDo you use recreational drugs? Y NList any medications you are taking: MedicationDosage/Freq.Prescriber Reason1._____________________________________________________________2._____________________________________________________________3._____________________________________________________________4._____________________________________________________________5._____________________________________________________________6._____________________________________________________________List any surgeries or hospitalizations you have had:Date(year)Surgery SurgeonReason__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________List and detail any medical condition or history not listed above:____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________Primary Physician’s Name: __________________________________________ Physician’s phone #: ______________________Are you under the care of other physicians? If so, please list:PhysicianPhone #Reason _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________GENERAL CONSENT TO DIAGNOSE AND TREAT: The undersigned hereby authorizes Dr. Reginald S. Young, LTD to take radiographs, study models, photographs, or any other diagnostic aids deemed appropriate to make a thorough diagnosis of the undersigned patient’s dental condition and needs. I authorize Dr. Reginald S. Young, LTD to perform any and all forms of treatment, medication, and therapy that may be necessary and further consent that Dr. Reginald S. Young, LTD choose and employ such assistance as deemed necessary. I understand that the use of local anesthetics agents embodies certain risk and consent to their use as deemed appropriate by Dr. Reginald S. Young, LTD. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect or incomplete information can be dangerous to my/ the patient’s health. It is my responsibility to inform the dental office of any change in medical health or status. FINANCIAL CONSENT: I understand that responsibility for payment of services provided in this office for myself and my dependent(s) is mine, due and payable at the time services are rendered. I understand that I am responsible for any portion of fees for services rendered not covered by my dental or medical insurance (if any). I further consent to and agree to pay a 2% finance charge (24% annually) that will be applied to any balance over 60 days. I acknowledge that I am responsible for all fees necessary to collect my account. I authorize Dr. Reginald S. Young, LTD and his staff to verify insurance coverage, if any, to submit claims and provide my insurance company with information required for a claim, to assign benefits, and to handle any necessary claim appeal(s). Consent (adult):Name of Patient ____________________________________________________________________________________Date __________________Signature of PatientConsent (for a minor child):Name of Parent/Guardian _______________________________________________________________________________Date __________________Signature of Parent/Guardian-190563500Notice of Privacy Practices (below)Patient privacy is important to our practice. We are required by law to maintain the privacy of Protected Health Information (“PHI”) and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. By signing below you are acknowledging receiving notice of our practices’ policies and your rights regarding PHI. I allow release of pertinent medical records to my insurance company (if applicable) and my other medical providers.___________________________________________Date __________________Signature of Patient00Notice of Privacy Practices (below)Patient privacy is important to our practice. We are required by law to maintain the privacy of Protected Health Information (“PHI”) and to provide individuals with notice of our legal duties and privacy practices with respect to PHI. By signing below you are acknowledging receiving notice of our practices’ policies and your rights regarding PHI. I allow release of pertinent medical records to my insurance company (if applicable) and my other medical providers.___________________________________________Date __________________Signature of Patient ................
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