FAMILY FIRST DENTAL OF COLUMBUS
DENTAL INNOVATIONS OF COLUMBUS
Kendra Pavlik DDS Michelle Bargen DDS
Date:_______________
Patient’s Information
Sex: οMale οFemale Marital Status: οMarried οSingle οDivorced οSeparated οWidowed
First Name:_________________________ Last Name:____________________ Middle Initial:_____ Preferred Name:__________
Mailing Address:_________________________________________City:___________________ State:_________ Zip:________
Home Phone: (_____)______-_________ Cellular: (_____)______-_________ Email:__________________________________
Birth Date:______/______/_______ Soc. Sec.: _______-______-_______Driver Lic #: ________________________
Student Status οFull Time οPart Time Name of School:__________________________ City:_______________ State:_____
Employment οFull Time οPart Time οRetired Name of Employer:____________________________ Phone #:_____________
Responsible for Account (If someone other than Patient) Sex: οMale οFemale
First Name:_________________________________ Last Name:_______________________________ Middle Initial:_______
Mailing Address:_________________________________________City:___________________ State:_________ Zip:________
Home Phone:______________________ Cellular:_____________________ Email:____________________________________
Birth Date:___________________________ Soc. Sec.: __________________________Driver Lic:________________________
Employer:___________________ Phone #: (_____)____________Marital Status: οMarried οSingle οDiv. οSeparated οWidowed
Emergency Contact Information (Family Member and Non Family Member)
Name:___________________________________ Relationship:______________________ Phone #: (______)______-______
Name:___________________________________ Relationship:______________________ Phone #: (______)______-______
Primary Dental Insurance Information
Sex: οMale οFemale Relationship of the Patient: οSelf οSpouse οChild οOther
Name of Insured:_______________________________ Birth Date:_____/_____/_____ Soc. Sec.: ______-_____-________
Employer________________________ Insurance Company:_____________________ ID Number:___________________
Secondary Dental Insurance Information
Sex: οMale οFemale Relationship of the Patient: οSelf οSpouse οChild οOther
Name of Insured:_______________________________ Birth Date:_____/_____/_____ Soc. Sec.: ______-_____-________
Employer________________________ Insurance Company:_____________________ ID Number:___________________
Other Information
Who may we Thank for Inviting you to our Practice? _____________________________________________________________
(Ex: Family, Friend, Phone Book, Social Media, On-Line Search, Billboard, Mailer, Newspaper, Radio, etc.)
Revised 05/2019
Medical History for _________________________
Although dental personal primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. If yes please use the following lines to answer.
Are you under a physician’s care now? οYes οNo-Name and # ____________________________________________
Have you ever been hospitalized or had a major operation? οYes οNo-Year and what for __________________________________
Have you ever had a serious head or neck injury? οYes οNo-Year and what for _______________________________________
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Are you taking any medications, pills, or drugs? οYes οNo
Do you take, or have you taken, Phen-Fen or Redux?οYes οNo
Are you taking any medication for osteoporosis? οYes οNo
Are you taking any blood thinners? οYes οNo
Do you use tobacco? οYes οNo
Do you use controlled substances? οYes οNo
Do you vape? οYes οNo
Are you allergic to any of the following?
οAspirin οPenicillin οCodeine οAcrylic οMetal οLatex ο Sulfa Drugs ο Local Anesthetics
οOther Please Explain: __________________________________________________________________________
Women: Are you
Pregnant/Trying to get pregnant? οYes οNo Taking oral contraceptives? οYes οNo Nursing? οYes οNo
Sleep Screening
Do you snore? οYes οNo
Do you have unrefreshed sleep or fatigue? οYes οNo
Current CPAP user? οYes οNo
Are you CPAP intolerant? οYes οNo
Has someone noticed you stopped breathing? οYes οNo
Have you ever had a sleep study? οYes οNo
Do you have, or have you had any of the following?
AIDS/HIV Positive οYes οNo
Alzheimer’s Disease οYes οNo
Anaphylaxis οYes οNo
Anemia οYes οNo
Angina οYes οNo
Arthritis/Gout οYes οNo
Artificial Heart Valve οYes οNo
Artificial Joint οYes οNo
Asthma οYes οNo
Blood Disease οYes οNo
Blood Transfusion οYes οNo
Breathing Problem οYes οNo
Bruise Easily οYes οNo
Cancer οYes οNo
Chemotherapy οYes οNo
Chest Pains οYes οNo
Cold Sores/Fever Blisters οYes οNo
Congenital Heart Disorder οYes οNo
Convulsions οYes οNo
Cortisone Medicine οYes οNo
Diabetes οYes οNo
Drug Addiction οYes οNo
Easily Winded οYes οNo
Emphysema οYes οNo
Epilepsy or Seizures οYes οNo
Excessive Bleeding οYes οNo
Excessive Thirst οYes οNo
Fainting Spells/Dizziness οYes οNo
Frequent Cough οYes οNo
Frequent Diarrhea οYes οNo
Frequent Headaches οYes οNo
Genital Herpes οYes οNo
Glaucoma οYes οNo
Hay Fever οYes οNo
Heart Attack/Failure οYes οNo
Heart Murmur οYes οNo
Heart Pace maker οYes οNo
Heart Trouble/Disease οYes οNo
Hemophilia οYes οNo
Hepatitis A οYes οNo
Hepatitis B or C οYes οNo
Herpes οYes οNo
High Blood Pressure οYes οNo
Hives or Rash οYes οNo
Hypoglycemia οYes οNo
Irregular Heartbeat οYes οNo
Kidney Problems οYes οNo
Leukemia οYes οNo
Liver Disease οYes οNo
Low Blood Pressure οYes οNo
Mitral Valve Prolapse οYes οNo
Pain in Jaw Joints οYes οNo
Parathyroid Disease οYes οNo
Psychiatric Care οYes οNo
Radiation Treatments οYes οNo
Recent Weight Loss οYes οNo
Renal Dialysis οYes οNo
Rheumatic Fever οYes οNo
Rheumatism οYes οNo
Scarlet Fever οYes οNo
Shingles οYes οNo
Sickle Cell Disease οYes οNo
Sinus Trouble οYes οNo
Spina Bifida οYes οNo
Stomach/Intestinal Disease οYes οNo
Stroke οYes οNo
Swelling of the limbs οYes οNo
Thyroid Disease οYes οNo
Tonsillitis οYes οNo
Tuberculosis οYes οNo
Tumors or Growths οYes οNo
Ulcers οYes οNo
Venereal Disease οYes οNo
Yellow Jaundice οYes οNo
Have you ever had any serious illness not listed above? οYes οNo
If yes, Please explain______________________________________________________________________________________
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patent’s) health. It is my responsibility to inform the dental office of any changes in medical status.
X________________________________________________________________________________________________
Signature of Patient/Guardian Date
Revised 05/2019
HIPPA/ FINANCIAL POLICIES for____________________________
Contact Information for Protected Health Information
I request that the following directives be adhered to for the disclosure of my Protected Health Information (PHI). This would include my name, diagnosis, x-rays, test results, date of services and financial information.
You may disclose information to my family and/or non-family members listed below:
Name:___________________________________ Relationship:__________________________ Phone #:_________________
Name:___________________________________ Relationship:__________________________ Phone #:_________________
ο You may leave Protected Health Information on my answering machine/voicemail using Phone #:___________________
ο You may send me a text message using Phone #:___________________
ο You may email me(unencrypted) for dental appointment’s. Email address: ____________________________________
I accept ο decline ο a copy of this office’s Notice of Privacy Practices.
X______________________________________________________________________________________________
Signature of Patient/Guardian Date
DENTAL INNOVATIONS OF COLUMBUS FINANCIAL POLICY
This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the most comprehensive dental care using only the highest quality material and technology available in the market today. We are also committed to providing you with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health. This Financial agreement is intended to facilitate our ability to provide excellent service to you while minimizing our costs to you.
Payment for Service is due at time services are rendered. Our practice accepts CASH, CHECKS, DEBIT OR CREDIT CARDS. No interest financing is also available through CARE CREDIT to qualified individuals. Returned checks and balances older than 60 days may be subject to collection fees and finance charges at a rate of 1.5% per month (18% annually).
Separated or divorced parents of minors who are responsible for half of the cost of a child’s dental care: The parent who brings the child into the dental appointment is responsible for paying the copayment or full fee. If it is necessary, we are happy to hold a Credit/Debit card number from the non-custodial parent on file.
As a courtesy to you, we will be happy to process all of your insurance claims. In order to do this, you must bring proof of your insurance with you to your appointment. All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is an agreement between you, your employer and the insurance company. Our practice is not a party to that agreement. If payment from your insurance company is not received within 60 days from the date of service, you will be expected to pay the balance in full. Your deductibles and any estimated co-payment for treatment is due at the time treatment is provided.
Additionally, our practice will charge $25 for appointments not kept and for appointments that are not rescheduled with at least 24 hours’ notice.
Please do not hesitate to ask if you have questions regarding this financial policy. We are committed to providing you with the best experience in dental care.
X________________________________________________________________________________________________
Signature of Patient/Guardian Date
Revised 05/2019
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