ProSites, Inc.



DENTAL/MEDICAL HISTORYPatient Name: ______________________________________________ DOB: ______________________ Sex: M/FAddress: _____________________________________ City: ______________________ Zip Code: _____________Telephone (Home):______________________Cell:___________________________ Name of Primary Physician: _______________________________ Telephone: _____________________________Person to notify in case of Emergency: _____________________ Telephone: ______________________________Do you have Dental Insurance: Yes/No, I am a Self-pay Patient.Plan: ___________________________________________ Group Number:___ _____________________________Policy Number: ____________________________________ Subscriber’s SSN: ____________________________How did you hear about us? Referral/Flyer/Radio/Other: ______________________________________________Are you in good health? ____________________________________________________________ Yes/NoAre you under the care of a Physician for any reason? ____________________________________ Yes/NoHave you ever had any serious illness/operation? _______________________________________ Yes/NoIf yes, explain: __________________________________________________________________________Do you have, or have you had any of the following:A)Rheumatic fever or rheumatic heart disease?Yes/NoI)Thyroid condition or surgery?Yes/NoB)Heart murmur, click or prolapsed mitral valve?Yes/NoJ)Diabetes?Yes/NoC)Heart trouble or heart attack?Yes/NoK)Hepatitis or liver disease?Yes/NoD)High blood pressure?Yes/NoL)Arthritis?Yes/NoE)Stroke?Yes/NoM)Stomach ulcers/stomach problems?Yes/NoF)Asthma or Bronchitis?Yes/NoN)Kidney disease?Yes/NoG)Fainting spells or seizures?Yes/NoO)Tuberculosis?Yes/NoH)HIV, AIDS, infectious disease?Yes/NoP)Anemia (Thin Blood)?Yes/NoDo your ankles swell during the day? __________________________________________________ Yes/NoHave you ever had a blood transfusion? _______________________________________________ Yes/NoAre you taking any drug or medicine for any reason? _____________________________________ Yes/NoDo you use tobacco products (smoke or chew tobacco)? __________________________________ Yes/NoAre you allergic or sensitive to any of the following drugs:Local anesthetics (Novocain)?_____________________________________________________ Yes/NoPenicillin, Erythromycin or any antibiotics? __________________________________________ Yes/NoOther medications. Please list:____________________________________________________ Yes/No 10. Have you ever had any trouble associated with dental treatment? ___________________________ Yes/No If so, explain: ___________________________________________________________________ 11. When was the last time you saw a dentist? ____________________________________________________ 12. Have you had any trauma to your teeth or jaws? _________________________________________ Yes/No 13. Are you in pain now? _______________________________________________________________ Yes/NoWomen Only: 14. Are you pregnant?_________________________________________________________________ Yes/No How many months?_______________Please list any MEDICATIONS currently taking::__________________________________________________________________________________________________________________________________________________________________________ ____________________________________________________________ __________________________ _______________________Please list any ALLERGIES or REACTIONS:__________________________________________________________________________________________________________________________________________________________________________________________Please list any OPERATIONS/HOSPITALIZATIONS in the last two years:__________________________________________________________________________________________________________________________________________________________________________________________“I hereby authorize Franklin Park Family Dental and Staff to evaluate, diagnose, and treat me as may be deemed necessary” ___________________________________________ Date: __________________________Patient Signature (Legal guardian if under 18) ____________________________________________ Date: __________________________Dentist/Hygienist SignatureNOTICE OF PRIVACY PRACTICESTHIS 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. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.OUR LEGAL DUTYWe are required by law to maintain the privacy of your health information. We are also required to give you the notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice. This notice will remain in effective until we replace it.We may change our privacy practices and the terms of this notice at any time, provided such changes are permitted by applicable law. We may make the changes in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we made the changes. You may request a copy of our notice at any time.USES AND DISCLOSURES OF HEALTH INFORMATIONWe may use and disclose health information about you for treatment, payment, and healthcare operations. For example:Treatment: We may use or disclose your health information to another dentist or healthcare provider providing treatment to you, or if we refer you to another health care provider.Payment: We may use and disclose your health information to obtain payment for services we provide to you. We may need to share part of your health information with our billing department, your insurance company, collection agencies, or attorneys assisting with collections and others who are responsible for your bills, such as your spouse, as necessary for us to collect payment. For example we may give information about a dental procedure that you had with your dental insurance company so it will pay us or reimburse you for your dental procedure.Healthcare operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, and licensing or credentialing activities.To your family, friends, or other persons involved in your care: We may share with a family member, friend, or other person identified by you, your health information that is directly related to that person’s involvement in your care or payment for your care, or to notify such individuals of your location or general condition, but only if you agree that we may do so, or based on our professional judgment, we determine that you would not object to the disclosure. We will also use our professional judgment and our experience in allowing a person to pick up supplies, x-rays, or other similar forms of health information on your behalf.Use and Disclose of Health Information required by law: We may use and disclose your health information when required by federal or state law, when required in court or administrative proceedings, for public health activities; to health oversight agencies; to coroners, medical examiners, and funeral directors; to the military; to federal officials for lawful intelligence and or domestic violence; to avert a serious threat to your health or safety or the health and safety of other; and as authorized by state worker’s compensation laws.Marketing Health related Services: We will not use your health information for marketing communications without your written authorization.Contacting you: We may use and disclose your health information to contact you about appointments and other matters, and to send you electronic billing statements. We may contact you by telephone, e-mail, or mail. We may leave you messages at the telephone number you gave us.Health related services: We may use and disclose your health information to send you information by mail or e-mail about our health related products and services available to your, general dental health news and information, and offers available only to our patients. We will tell you how to cancel these communications.Your Authorization: As explained in this notice, we may use and disclose your health information for treatment, payment, or health care operations; in certain situations if you agree or object; as required by law; to contact you; and to send your health information for any other reason without your written authorization. You may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you already give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any uses or disclosures already made with your authorization while it was in effect.PATIENT RIGHTSRight to see and copy your health information: You have the right to see or get copies of your health information, with limited exceptions. If we deny your request due to one of these exceptions, we will respond to you in writing with the reason we cannot grant your request, and describe any rights you may have to request a review of our denial. You must make a witness request us to access your health information. Your written request must be signed and dated. We may charge you a fee for expenses such as copies, staff time, and postage. Instead of providing you with a copy of your health information, we may prepare a summary or an explanation of your health information for a fee, if you agree in advance to the form and fee of the summary or explanation.Right to Accounting of Disclosures of your health information: You have the right to receive a list of insurances in which we or our business associated disclosed your health information for purposes other than treatment, payment, and healthcare operations or certain other activities. If you request this accounting more than once in a 12-month period, we may charge you a fee for responding to these additional requests. You must submit a written request that is signed and dated.Right to request restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information, including uses or disclosures for treatment, payment, and healthcare operations, and to family members, friends, or others involved in your care or payments for your care. You must submit a written request that is signed. We are not required to agree to these additional restrictions, but if we do we will abide by our agreement (except in certain situations, such as to provide you with emergency treatment).Right to request alternate communication: You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. For example, you can ask that we only contact you at work, or only by mail. You must make your request in writing and your request must be signed and dated. Your request must specify the ways in which you wish to be contacted. You do not need to tell us the reason for your request.Right to request amendment: You have the right to request that we amend your health information. You must submit a written request that is signed and dated. Your request must explain why your health information should be amended. Your request must be submitted to the Privacy Officer, 5875 Landerbrook Drive, Suite 250, Mayfield Heights, OH 44124. If we deny your request, we will respond to you in writing with the reason we cannot grant your request and explain your options.QUESTIONS AND COMPLAINTSIf 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, 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 US Department of Health and Human Services.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 US Department of Health and Human Services.Should you wish to contact us, you may do so at the address and telephone number below.Franklin Park Family Dental614 B Blue Hill AveDorchester, MA 02121Telephone: (617) 287 0007Signature: ______________________________________________________ Date: ______________________________GENERAL CONSENT FORMPATIENT: _________________________________________________________________________MEDICAL HISTORY INFORMATIONPlease understand that it is important that you divulge any information about your medical history to your dentist. It is important that you inform us of any medicines that you are taking each time you come to an appointment as some medications can cause harmful reactions with dental anesthetics, analgesics, antibiotics or other medications. Please be sure to provide us with a list of any drug allergies you have.DRUGS AND MEDICATIONSI understand that antibiotics, anesthetics, analgesics and other medications can produce allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock. Some medications that I might be currently taking could produce undesired effects or interfere with the normal process of healing (for example aspirin could produce excessive bleeding during extractions, etc.). I understand that filling out the health questionnaire out to the best of my knowledge is important in order to be prepared for any recommended procedure.RESTORATIONSI understand that sensitivity may occur after a newly placed filling. I understand that care must be exercised in chewing on new fillings especially during the first 24hours to avoid breakage. I understand that a more extensive filling than originally diagnosed may be required due to additional decay. I understand that sensitivity is a common after effect of a newly placed filling. If the sensitivity continues, I understand that a root canal may be needed, even though the tooth may not have hurt prior to the fillings being done. I understand that sometimes it is not possible to match the color of natural teeth exactly with white fillings (Composites) especially when replacing existing metal fillings.CROWNS, BRIDGES AND CAPSI 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 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. It is also my responsibility to return for permanent cementation within 20days from tooth preparation. Excessive delays may cause tooth movement or recurrent decay. This may necessitate a remake of the crown, bridge, or cap. I understand that a root canal may be needed, even though the tooth may have not hurt prior to the crown or bridge having been done. I understand there will be additional charges for remakes due to my delaying permanent cementation. I understand that the remaking of existing crowns or bridges imply certain risks like pulp involvement, fracture of root, etc., that could lead to further unexpected procedures.ENDODONTIC TREATMENT (ROOT CANAL)I realize that there is no guarantee that root canal treatment will save my tooth, and that complications can occur from treatment, and that occasionally root canal filling may extend beyond the tooth root which does not necessarily affect the success of the treatment. I understand that endodontic files and reamers are very fine instruments and stresses vented in their manufacture can cause them to separate during use. I understand that the tooth may be lost in spite of all efforts to save it.PERIODONTAL TREATMENTI understand that I have a condition, causing gum and bone inflammation that can lead to loss of teeth. Alternative treatment plans have been explained to me, including Deep cleaning, gum surgery, locally administered antibiotics, bone replacements and/or extractions. I also understand that the success of the periodontal treatment depends not only on the procedure performed but also on the daily personal care. (Brushing and flossing)DENTURESSore spots, altered speech, and difficulty in eating are common problems with new dentures. The ability to adapt to removable dentures varies widely. In some cases, a patient cannot or will be able to use the device through no fault of fabrication. Immediate denture (placement of denture immediately after extractions) may be painful. Immediate denture may require considerable adjusting and several relines. A permanent reline will be needed. This is not included in the denture fee. I understand that it is my responsibility to return for delivery of the dentures. I understand that failure to keep my delivery appointment may result in poorly fitted dentures. If a remake is required due to my delays of more than 30days, there will be additional charges.CHANGES IN TREATMENT PLANI 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, for example, root canal therapy following routine restorative procedures. I give permission to the Dentist to make any/all changes and additions as necessary after PLICATIONSComplications resulting from the use of dental instruments, drugs, sedation, medicines, and analgesics (pain killers), anesthetics, and injections include ( but not limited to) swelling, sensitivity, bleeding, pain, infection, numbness and tingling sensation in the lip, tongue, chin, gums, cheeks, and teeth.. (Which is transient but on infrequent occasion, may be permanent), reaction to injections, changes in occlusion (biting), jaw muscle cramps and spasms, temporoandibular (jaw) difficulty, referred pain to ear, neck, and head, nausea, vomiting, allergic reactions, delayed healing and treatment failure. The risk of complications from medications used/prescribed with general dental treatment include, but are not limited to, drowsiness, lack of awareness and coordination, nausea, allergic reactions, etc. (which may be influenced by the use of alcohol, tranquilizers, sedatives or other drugs). It’s not advisable to operate any motor vehicle or hazardous device while experiencing side effects of the medications we may prescribe.) Antibiotics are known to decrease the effectiveness of oral contraceptives, so it’s advised that other contraceptive measures be taken during the administration of antibiotics.XRAYS AND PHOTOGRAPHSModern dental x-ray equipment is extremely low dose radiation. Diagnostic x-rays provide the dentist with valuable information about your teeth and supporting bone that cannot be evaluated otherwise. Our office takes the minimum x-rays to allow us to do a thorough exam for each patient. All patients 18 years and older will receive a full mouth series of intra-oral x-rays. Without these x-rays, we cannot do a complete exam of the entire mouth and jaw. We may also take photos of our patients as part of their permanent record. We will not release these photos to anyone without your permission.MINORSWe must receive written consent prior to performing any non-emergency dental procedures on a minor. Grandparents, step-parents, friends, relatives, etc. are not legally allowed to consent to dental procedures, unless they have been given written consents by the parent or legal guardian. Please do not send your child to an appointment alone or with someone other than yourself, unless you have filled out any necessary consent form prior to the appointment, otherwise we may have no choice but to reschedule your child’s appointment to another day.LIMITED ORAL EXAMSIn the event that a patient requests only a specific problem be addressed (i.e. broken tooth; pain in one area, etc.) this is considered a problem focused evaluation. X-rays will be taken in this specific area only, and a complete comprehensive examination will not be done. The dentist cannot diagnose problems in other areas of the mouth. Please understand that this appointment will be for the treatment/diagnosis of an emergency/urgent need. Any future treatment of other areas will require additional x-rays and a complete exam. You will not be considered a patient of record unless this examination is completed.SPECIALITY REFERRALSGeneral dentist perform the majority of all dental treatment today. However, we want all patients to be aware that specialty fields exist in dentistry, particularly in the fields of oral surgery, orthodontics, periodontics, pediatric dentistry, and endodontics. In some cases we may have to refer certain procedures out to a specialist. We would be happy to offer you the names of specialists in order for you to have a second opinion and/or have actual treatment performed by a specialist. I hereby authorize the dental staff to proceed with and perform the dental restorations and treatments as explained to me. I understand that this is only an estimate and subject to modification depending on unforeseen or undiagnosable circumstances that may arise during the course of treatment. I understand that regardless of any dental insurance coverage I may have. I am responsible for payment of dental fees. I agree to pay any attorney’s fee, collection fees, or court costs that may be incurred to satisfy this obligation.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 that I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfactions.Patient, Parent or Guardian’s Signature:Date:Doctor’s Signature:Date:Witness Signature:Date: ................
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