Patient Information in sequence.indd



342900-53975DENTAL IMPLANT GROUPChad S Lewison, DDS – Associate Fellow of the American Academy of Implant DentistryKevin Haiar, DDSBlake Hult, DDS1110 West 5th Street, Canton, SD 57013 Phone (605) 764-3179 ? Toll Free (866) 516-0570 ? Fax (605) 764-3181PATIENT INFORMATION:Last Name: ________________________ First Name: _____________________ Middle: ________Preferred Name: __________________ Date of Birth: ____________Sex: □ Male □ Female Mailing Address: _____________________ City: _________________ State: ______ Zip: ________Home Phone: _______________ Cell Phone: ________________ Work Phone: _______________SS#: _________________ Emergency Contact Name & Phone: ____________________________Medical Doctor’s Name: __________________ Phone # of Medical Doctor: ________________Name of Preferred Pharmacy: ______________________ Pharmacy Phone #: ______________How did you hear about our office?Doctor Referral _________________________Patient Referral ________________________□ Phone Book Ad □ Internet Search □ Website □ Other ______________________________DENTAL INSURANCE INFORMATION:Primary Insurance Co: _________________________ Address: ______________________________City: ___________________ State: ________ Zip: ___________ Phone: _________________________Policy Holder: __________________________ Relationship to Patient: ______________________Date of Birth: _______________ Group/Policy #: ___________ ID/SS #: ______________________I authorize the release of a full report of examination findings, diagnosis, treatment planning, etc., to any referring dentist or physician. I additionally authorize the release of any dental/medical information to insurance companies or for legal documentation to process claims. I understand that I am responsible for all charges for treatment to me regardless of insurance coverage.Patient Signature: __________________________________________ Date: _______________________PLEASE CHECK ANY OF THE FOLLOWING THAT HAVE CAUSED AN ALLERGIC REACTION:Antibiotics□ PenicillinAspirin□ SedativesCodeine□ Sleeping AidsLatex□ Sulfa DrugsLocal Anesthetics□ Other Allergies MetalsPLEASE CHECK ANY OF THE FOLLOWING THAT YOU HAVE OR HAVE HAD:Abnormal Bleeding / Bleed Easily□ Heart PacemakerAnemia□ Heart PalpitationsArthritis, Rheumatism□ Heart Valve ReplacementAsthma□ Heart Valve DamageAutoimmune Disorder (HIV or AIDS)□ Hemophilia□ Bloating□ Hepatitis: □ A □ B □ CCancer□ High Blood PressureChemotherapy□ HypoglycemiaChemical / Substance Dependency□ HyperglycemiaChronic Dry Mouth□ Intestinal DisordersChronic Bronchitis□ JaundiceChronic Fatigue□ Joint Pain / StiffnessCold Hands / Feet□ Kidney ProblemsColitis□ Liver DiseaseCurrent Pregnancy / Nursing□ Lung DiseaseDepression / Emotional Problems□ Meniere’s DiseaseDiabetes□ Muscle Aches, Spasms, CrampsDizziness□ Muscular DystrophyEmphysema□ Multiple SclerosisEpilepsy / Seizures□ NeuralgiaExcessive Thirst□ OsteoporosisFainting Spells□ Parkinson’s DiseaseFluid Retention□ Poor CirculationFrequent Cough□ Prior Orthodontic TreatmentFrequent Headaches□ Psychiatric CareFrequent Illnesses□ Radiation TreatmentFrequent Urination□ Rheumatic FeverGout□ Scarlet FeverHay Fever / Sinus Problems□ Shortness of BreathHeart Disease□ Skin DisorderHeart Attack, Heart Defects□ Slow Healing SoresHearing Impairment□ Speech DifficultiesHeart Murmur□ Stomach UlcersTuberculosis□ Thyroid _____________________Urinary Disorder□ NeuropathyDO YOU HAVE OR HAVE HAD THE FOLLOWING:Blood Transfusions Artificial Joints Contact LensesSurgeries DO YOU TAKE OR HAVE YOU TAKEN:Alcohol□ Bisphosphonates: Fosamax, Boniva, etc.Recreational Drugs□ Birth Control PillsTobacco in any form□ Pre-Med for Dental ProceduresPLEASE LIST ANY PRESCRIBED MEDS & OVER THE COUNTER MEDS YOU ARE CURRENTLY TAKING:342900138430004137025138430003429001301750041370251301750034290013081000413702513081000PLEASE LIST ANY OTHER DISEASES OR MEDICAL PROBLEMS NOT LISTED ON THIS FORM.3429001384300034290013017500342900-170508Dental Implant GroupAcknowledgement of Receipt of Notice of Privacy Practices**You May Refuse to Sign This Acknowledgement**I, , have received a copy of this office’s Notice of Privacy Practices.97155014605000Print Name91440017462500Signature91440020447000Date342900368300034290055499000FOR OFFICE USE ONLYWe attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communication barriers prohibited obtaining acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please specify)34290023876000 ................
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