Wauka Mountain Family Dentistry



Wauka Mountain Family DentistryDr. Lora Savage D.M.D.PATIENT REGISTRATIONPatient First Name:_____________________ Last Name:_______________________ Middle Initial:__________ Mailing Address:_____________________________ City_________________________ State_______ Zip_____________ Home Phone:___________________ Work Phone: _____________________ Ext:_______ Cellular:___________________ E-Mail ______________________________________________ □ I would like to receive email confirmation of appointments.Age ________ Birth Date: ____________ Soc Sec #: ____________________ Drivers Lic #: _________________________ Sex: □ Male □ Female Marital Status: □ Married □ Single □ Divorced □Separated □ Widowed □ PartneredI would like to be contacted at □ home □ cell □ work. Spouse ________________________________________________Employer/School _____________________________ Whom may we thank for referring you? ___________________________. Emergency contact: Name: _______________________, Relationship: ________________ Contact Number: ______________Patient Is: □ Responsible Party □ Policy HolderResponsible Party (if someone other than the patient) First Name:________________________________ Last Name:________________________________ Middle Initial: ______ Address: ___________________________________________ Address 2:__________________________________ City ________________________________________, State ______________ Zip: ________________ Home Phone: _____________________Work Phone: ___________________ Ext:_________ Cellular: _______________ E-Mail ______________________________________________ □ I would like to receive correspondence via email. Age ________ Birth Date: ____________ Soc Sec #: ____________________ Drivers Lic #: ___________________________ Responsible Party is also: □ Policy Holder for Patient □ Primary Insurance Policy Holder □ Secondary Insurance Policy HolderPrimary Insurance Information: (Policy Holder)Employer: _________________ Ins. Company: ___________________Group # _____________ ID #_____________Name (If different than patient) First Name:_________________ Last Name:____________________ Middle Initial: ______ Patient Relationship to Insured: □ Spouse □ Child □ OtherInsured Soc. Sec: __________________________ Insured Birth Date: _________________________________Mailing Address: _______________________________________ City __________________________________, State ________________ Zip: _________________Secondary Insurance Info: (Policy Holder) Employer: _________________ Ins. Company: ___________________Group # _____________ ID #_____________Name (If different than patient) First Name:_________________ Last Name:____________________ Middle Initial: ______ Patient Relationship to Insured: Spouse Child Other. Insured Soc. Sec: ________________ Insured Birth Date: ________________________Mailing Address: _______________________________________ City __________________________________, State ________________ Zip: _________________I understand that I am responsible for all charges whether or not paid by insurance. I assign directly to Dr. Savage all insurance benefits, if any, otherwise payable to me for services rendered. I authorize the use of my signature on all insurance submissions. ________________________________________ (Signature of Patient or Parent/Guardian)MEDICAL HISTORYAlthough dental personnel 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 medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Physician's Name_______________Are you under a physician’s care now?□Yes □No If yes, explain_________________________Have you ever been hospitalized or had a major operation?□Yes □No If yes, explain_________________________ Have you ever had a serious head or neck injury?□Yes □No If yes, explain ________________________ Are you taking any medications, pills, or drugs?□Yes □No If yes, explain ________________________ Do you take, or have you taken, Phen-Fen or Redux?□Yes □No If yes, explain ________________________ Are you on a special diet?□Yes □No If yes, explain ________________________ Do you use tobacco?□Yes □No Which type?__________________________ Do you use controlled substances?□Yes □NoIf yes, explain_________________________ Women: Are you: Pregnant/Trying to get pregnant? □Yes □No Taking Oral Contraceptives? ?□Yes □?No Nursing? □Yes □NoAre you allergic to any of the following? Aspirin Penicillin Codeine Local Anesthetics Sulfa Drugs Latex Acrylic Other __________Do you have or have had any of the following?AIDS/ HIV Positive?Yes ?NoConvulsions?Yes ?NoHeart Pacemaker?Yes ?NoAlzheimer’s Disease?Yes ?NoCortisone Medicine?Yes ?NoHeart Trouble/Disease?Yes ?NoAnaphylaxis?Yes ?NoDiabetes?Yes ?NoHemophilia?Yes ?NoAnemia?Yes ?NoDrug Addiction?Yes ?NoHepatitis _____ (A,B,or C) ?Yes ?NoAngina?Yes ?NoEasily Winded?Yes ?NoHerpes?Yes ?NoArthritis/Gout?Yes ?NoEmphysema?Yes ?NoHigh Blood Pressure?Yes ?NoArtificial Heart Valve?Yes ?NoEpilepsy/Seizures?Yes ?NoHigh Cholesterol?Yes ?NoArtificial Joint?Yes ?NoExcessive Bleeding?Yes ?NoHives/Rash?Yes ?NoAsthma?Yes ?NoExcessive Thirst?Yes ?NoHypoglycemia?Yes ?NoBlood Disease?Yes ?NoFainting/Dizzy Spells?Yes ?NoIrregular Heartbeat?Yes ?NoBlood Transfusion?Yes ?NoFrequent Cough?Yes ?NoKidney Problems?Yes ?NoBreathing Problem?Yes ?NoFrequent Diarrhea?Yes ?NoLeukemia?Yes ?NoBruise Easily?Yes ?NoFrequent Headaches?Yes ?NoLiver Disease?Yes ?NoCancer?Yes ?NoGenital Herpes?Yes ?NoLow Blood Pressure?Yes ?NoChemotherapy?Yes ?NoGlaucoma?Yes ?NoLung Disease?Yes ?NoChest Pains?Yes ?NoHay Fever?Yes ?NoMitral Valve Prolapse?Yes ?NoCold Sore/Fever Blisters?Yes ?NoHeart Attack/Failure?Yes ?NoOsteoporosis?Yes ?NoCongenital Heart Disorder?Yes ?NoHeart Murmur?Yes ?NoParathyroid Disease?Yes ?NoPsychiatric Care?Yes ?NoRadiation Treatment?Yes ?NoRecent weight loss?Yes ?NoRheumatic Fever?Yes ?NoRheumatism?Yes ?NoScarlet Fever?Yes ?NoSickle Cell Disease?Yes ?NoSinus Trouble?Yes ?NoSpina Bifida?Yes ?NoTonsilitis?Yes ?NoTuberculosis?Yes ?NoTumors/Growths?Yes ?NoVenereal Disease?Yes ?NoYellow Jaundice?Yes ?NoRenal Dialysis?Yes ?NoShingles?Yes ?NoStomach/Intestinal Disease?Yes ?NoUlcers?Yes ?NoDo you have or have you ever had any serious illness/disability not listed above? ?Yes ?No If yes, please explain ________________________Dental HistoryReason for today’s visit____________________ Former Dentist _________________ City/State_________________________Date of last dental visit__________ Date of last dental x-rays________ How often do you brush __________ floss_________Have you had any dental surgeries? ?□ Yes □ No. If yes, please explain _________________________________________________Bad Breath ?Yes ?NoClicking or popping jaw ?Yes ?No Jaw pain or tiredness ?Yes ?No Bleeding Gums ?Yes ?NoDry Mouth ?Yes ?NoLip/Cheek biting ?Yes ?NoBlisters on lip/mouth ?Yes ?NoBiting fingernails/objects ?Yes ?NoLoose teeth or broken fillings ?Yes ?NoBurning sensation on tongue ?Yes ?No Grinding Teeth ?Yes ?NoMouth Pain ?Yes NoChew on one side of mouth ?Yes ?NoGums swollen/tender ?Yes ?NoMouth breathing ?Yes?NoOrtho Treatment ?Yes ?NoPeriodontal Treatment ?Yes ?NoSensitivity to hot ?Yes?NoSensitivity to biting ?Yes ?NoSensitivity to sweets ?Yes ?NoSensitivity to cold ?Yes NoSores/Growths in mouth ?Yes?NoPain around ear ?Yes?NoFood collection between teeth ?Yes?No 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 patient’s) health. It is my responsibility to inform the dental office of any changes in medical status._______________________________________________________________________________ Signature of Patient/Parent or Guardian DateWauka Mountain Family Dentistry, P.C. Dr. Lora Savage, DMDSection A: Patient Giving Consent:Name: ________________________________ Date: ______________________Section B: PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY.Purpose of Consent: By using this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain all the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting our office at 770-983-9496.RIGHT TO REVOKE: You will have the right to revoke this Consent at any time by giving us written notice of your revocation. Please understand that revocation of this consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or continue treating you. If you wish to revoke this consent, ask for an additional form to sign.SIGNATURE: I, ______________________________________, have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.Signature: _________________________ Date: _________________________If this Consent is signed by personal representative of the patient complete the following:Personal Representative’s Name: ____________________________________Relationship to the patient: __________________________________________Upon request, you are entitled to a copy of this consent.Consent to Perform DentistryI hereby authorize and direct the dentist, Dr. Lora Savage and/or dental auxiliaries of her choice, to perform the following dental treatment or oral surgery procedure (s), including the use of any necessary or advisable local anesthesia, radiographs (x-rays), or diagnostic aids.Preventive hygiene treatment (prophylaxis) and the application of topical fluoride.Application of plastic “sealants” to the grooves of the teeth.Treatment of diseased or injured teeth with dental restorations (fillings and crowns).Replacement of missing teeth with dental prosthesis (bridges, partial dentures, full dentures)Removal (extraction) of one or more teeth.Treatment of diseases or injured oral tissues (hard and/or soft)Use of sedative drugs to control apprehensionTreatment of malposed (crooked) teeth and/or oral developmental or growth abnormalities.Use of nitrous oxide/oxygen (laughing gas) anesthesia to accomplish the necessary treatment.I understand that there are risks involved in this treatment and hereby acknowledge that these risk(s) will be explained to me, that I will have an opportunity to ask questions regarding the treatment and the risks, and that I fully understand the same.I agree to the use of local anesthesia and the use of nitrous oxide/oxygen analgesia depending on the judgment of the doctor. Nitrous oxide/oxygen may occasionally produce nausea and vomiting. I am also aware that the nosepiece leaves an indention or ring around the nose, which disappears shortly after the procedure. I understand and have been informed of the above risks and complications.I recognize that during the course of treatment unforeseen circumstances may necessitate additional or different procedures from those discussed. I therefore authorize and request the performance of any additional procedures that are deemed necessary or desirable to oral health and well being in the professional judgment of the dentist.There are possible risks and complications associated with the administration of local anesthesia, sedation and drugs. The most common of these are swelling, bleeding, pain, nausea, vomiting, bruising, tingling, and numbness of the lips, gums, face and tongue, allergic reactions, hematoma (swelling and/or bleeding at or near the injection site), fainting, lip and cheek biting resulting in ulceration and infection of the mucosa. I also understand that there are rare potential risks such an unfavorable reactions to medicines in respiratory and cardiovascular collapse (stopping of breathing and heart function) and lack of oxygen to the brain that could result in coma or death. I understand and have been informed of the above risks and complications.I also authorize the doctors to use photographs, radiographs, other diagnostic materials and treatment records for the purpose of teaching, research and scientific publications.I will be advised that the success of the dental treatment to be provided will require that the patient and the parents follow post-operative and post-care instructions of the dentist. I agree that the success of the treatment requires that all post-operative and post-care instructions be followed and that regular office visits as scheduled by my dentist and his/her auxiliaries must be maintained.I hereby state that I have read and understand this consent, and that all questions about the procedure will be answered in a satisfactory manner; and I understand that I have the right to be provided answers to questions, which may arise during and after the course of my treatment.I further understand that this consent will remain in effect until such time that I choose to terminate it.Date: __________________ Time: _________Patient’s Name: __________________________Name of Parent or Guardian: ___________________________Relationship to Patient:_________________ __________________________________SIgnature of patient or Parent/Guardian________________________Witness ................
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