Patient Information
PETER H. PRUDEN, D.D.S.*, P.C.
75 Prospect Street, Rear Bldg., Suite 401
Huntington, NY 11743 631-421-2471
*Diplomate of the American Board of Oral and Maxillofacial Surgery
* Diplomate of the American Dental Society of Anesthesiology
* Fellow of the American College of Dentists
Patient Information revised Feb. 2020
Purpose of Visit: _________________________ Date: ____-____-______
Email: ___________________________ Referring Dentist: _______________________
Patient Name (Last, First, M.I.)_________________________________________
Street Address: ____________________________________________________
City: ____________________ State: ______ Zip Code: _____________
Home Phone: _______________________ Cell Phone: _____________________
Work Phone: _____________________ Date of Birth:____-____-_____ Age:_______
Social Security #: _____________________ Sex: M F Martial Status: M, S, DP, D, W
Student Status: ______________ Full Time: Yes NO Part Time: Yes NO
Name of School: ________________________Medical Physician:__________________
In Case Of Emergency
Contact Name: __________________ Phone Number: _____________________
Address: ________________________________________________________________
Responsible Party Self
Method of Payment: Cash ___ Check ____ Credit ____ Care Credit ______
Name (parent/guardian): ___________________ Date of Birth: _____________
Social Security #: _______________ Relationship: __________________________
Address: __________________________________ City: _____________________
State: ________ Zip Code: _________ Phone Number: _______________________
Current Employer: _____________________ Work Number: _______________________
Pharmacy: __________________________ Phone: ____________________
Town: ________________________ Road: ___________________
|High/Low Blood Pressure |Y |N |Chest Pain |Y |N |
|Heart Murmur or Rheumatic Fever, MVP-Mitral Valve Prolapse |Y |N |Ankles Swollen |Y |N |
|Heart Disease |Y |N |Glaucoma |Y |N |
|Diabetes |Y |N |Thyroid Condition |Y |N |
|Bleeding Tendencies |Y |N |Seizure Disorder |Y |N |
|Allergies |Y |N |Blood Disease |Y |N |
|Asthma |Y |N |Cortisone Therapy |Y |N |
|G.I. Neurological, Kidney, Liver, or Lung Disease |Y |N |Hepatitis A B or C |Y |N |
|Under Medical Care |Y |N |HIV/AIDS |Y |N |
|Pregnant, Nursing, Taking Birth Control |Y |N |Intravenous Drug User/ Blood Transfusion before 1992 |Y |N |
|Please circle all that apply. | | | | | |
|Osteoporosis |Y |N |Reactions to Local Anesthesia |Y |N |
|Bone Cancer |Y |N |Reactions to Codeine |Y |N |
|Any other cancer |Y |N |Reactions to Penicillin |Y |N |
|Chemo Therapy, Radiation, |Y |N |Reactions to Other Drugs |Y |N |
|Fosomax, Boniva, Actonel, Vivitrol | | | | | |
|Arrhythmia, Premature Ventricular Contractions, Atrial |Y |N |Reactions to General Anesthesia |Y |N |
|Fibrillation, | | | | | |
|Have you travelled outside the country in the last 21 days; if so |Y |N |Are you feeling feverish? |Y |N |
|where______________ | | | | | |
|Please list all Medications: |
|If NONE check here:____ |
|Please list all Allergies: |
|If NONE check here:___ |
|Have you ever had previous anesthesia/surgery? |
|Why? |
|Have you ever been hospitalized? |
|If yes for what and when? |
|Do you have any tattoos or body piercings? |
|If yes how many: |
|Do you smoke? |
|If yes how much per day: |
|Have you ever taken bisphosphonates Fosomax, Actonel, or Boniva? |
|If yes please list dates started and stopped: |
|Have you ever received intravenous bisphosphonates such as Zometa (Zoledranate) or Pamidronate (Aredia)? |
|If yes please list dates started and stopped: |
|Are your presently under the care of a physician? |
|Name: Phone Number: |
|When did you last eat or drink? |
INSURANCE INFORMATION
Primary Dental Insurance:
Primary Dental Ins. ______________________________ID#__________________
Mailing Address (on back of card) __________________________Group#:____________
City____________________ State _________ Zip code_____________
Insured’s Name____________________________ Date of Birth________________
Social Security #___________________ Relationship to Patient______________
Insured’s Address_____________________________________________________
City_______________ State_________ Zip code___________ Phone#_____________
Current employer_________________________ Work # __________________
Address________________________________________________________________
City___________________ State______ Zip code__________
Secondary Dental Insurance:
Secondary Dental Ins. -____________________________ID#__________________
Mailing Address (on back of card) _________________________Group#:_____________
City______________________ State________ Zip code____________
Insured’s Name____________________________ Date of Birth________________
Social Security #___________________ Relationship to Patient______________
Insured’s Address_____________________________________________________
City_______________ State_________ Zip Code___________ Phone#______________
Current employer_______________________ Work Phone # __________________
Address________________________________________________________________
City___________________ State______ Zip code__________
Primary Medical Insurance: (If applicable)
Primary Medical Ins. -______________________________ID#__________________
Mailing Address (on back of card) ________________________________________
City______________________ State________ Zip code____________
Group #___________________________________
Insured’s Name____________________________ Date of Birth________________
Social Security #___________________ Relationship to Patient______________
Insured’s Address_____________________________________________________
City_______________ State_________ Zip Code__________ Phone# _______________
Current employer_______________________ Work #_____________________
Address________________________________________________________________
City___________________ State______ Zip code__________
Secondary Medical Insurance:
Secondary Medical Ins. ______________________________ID#___________________
Mailing Address (on back of card) ________________________________________
City______________________ State________ Zip code____________
Group #______________________________________
Insured’s Name____________________________ Date of Birth________________
Social Security #___________________ Relationship to Patient______________
Insured’s Address_____________________________________________________
City_______________ State_________ Zip Code__________ Phone#_______________
Current employer_______________________ Work #_____________________Address_______________________________________City___________________ State______ Zip code__________
Release of Information Statement
I certify that the information given by me on this form is correct. All fees given by insurance company representatives and/or Dr. Pruden’s staff are Estimates and not GUARANTEED PAYMENT/ PRICING from insurance companies. I hereby assign benefits to Dr. Pruden and understand that I/legal guardian am responsible for full payment of services rendered and/or deductibles and co-payments or remaining balance after insurance companies have paid Dr. Pruden.
►X_____________________________________ Date:_______________
Medicare Patients: Almost all dental procedures are not covered by Medicare. I understand that I am responsible for insurance deductibles on all services, and 20% co-insurance on ancillary services which are covered.
►X_____________________________________ Date: ________________
I ________________________(DO____/DO NOT____) give permission for any doctor and staff member of Peter H. Pruden DDS PC to speak with a family member or individual regarding appointments, prescriptions, financial matters, test results, records and xrays and the pick up of such on your behalf.
Please list the individuals that we may speak with:
Name:_________________________Relationship_______________Phone #_____________
Name:_________________________Relationship_______________Phone #_____________
I WILL ALLOW____OR WILL NOT ALLOW___ the office of Peter H. Pruden DDS PC and Associates to contact me vial email or voicemail regarding appointments, prescriptions, financial matters, test results, records, xrays and the pick up of such.
Collection Fee
Should there be need to turn over your account to our collection agency, your account will be charged additional reasonable fees including a late fee as well as a collection fee.
►X____________________________________ Date: _____________
HIPPA Acknowledgement of Receipt of Privacy Practices
I, ________________________________________, have received a copy of this office’s Privacy Practices.
Please Print Name
►________________________________________ _______________________
Signature Date
Acknowledgement of Insurance Responsibilities
I, _________________________________________, have been informed that I am responsible for all fees if I do not have insurance in which Dr. Peter H. Pruden DDS is a participating provider. If I have insurance in which Dr. Peter H. Pruden DDS is a participating provider, I am responsible for all fees my insurance provider does not pay.
►_________________________________________ ____________________________
Signature Date
PETER H. PRUDEN, D.D.S.*, P.C.
75 Prospect Street, Rear Bldg., Suite 401
Huntington, NY 11743 631-421-2471
*Diplomate of the American Board of Oral and Maxillofacial Surgery
* Diplomate of the American Dental Society of Anesthesiology
* Fellow of the American College of Dentists
COVID‐19 PANDEMIC EMERGENCY DENTAL TREATMENT NOTICE AND
ACKNOWLEDGEMENT OF RISK FORM
Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the COVID‐19 virus. The COVID‐19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID‐19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting COVID‐19 associated with dental care.
The COVID‐19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID‐19 is challenging and complicated due to limited availability for virus testing.
Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office. Dental procedures create water spray which is one way the disease is spread. The ultra‐fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID‐19 virus to those nearby.
You cannot wear a protective mask over your mouth to prevent infection during treatment as your health care providers need access to your mouth to render care. This leaves you vulnerable to COVID‐19 transmission while receiving dental treatment.
Pursuant to statements from the Center for Disease Control (CDC) and the American Dental Association (ADA), non‐ essential or elective treatment, based on the assessment of our staff, will be rescheduled. According to the ADA, dental emergencies are “potentially life threatening and require immediate treatment to stop ongoing tissue bleeding [or to] alleviate severe pain or infection.” The ADA also recommends that urgent dental care which “focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments” be provided in as minimally invasive a manner as possible.
I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I further confirm I am seeking treatment for a condition that meets the emergent or urgent criteria noted above. I understand and accept the additional risk of contracting COVID‐19 from contact at this office. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here. I have read and understand the information stated above:
Signature ________________________________ Date ______________________________
PETER H. PRUDEN, D.D.S.*, P.C.
75 Prospect Street, Rear Bldg., Suite 401
Huntington, NY 11743 631-421-2471
*Diplomate of the American Board of Oral and Maxillofacial Surgery
* Diplomate of the American Dental Society of Anesthesiology
* Fellow of the American College of Dentists
COVID‐19 PANDEMIC ‐ PATIENT DISCLOSURES
This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID‐19 virus.
A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID‐19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us
It is also important that you disclose to this office any indication of having been exposed to COVID‐19, or whether you have experienced any signs or symptoms associated with the COVID‐19 virus.
| |Yes |No |
|Do you have a fever or above normal temperature? |□ |□ |
|Have you experienced shortness of breath or had trouble breathing |□ |□ |
|Do you have a dry cough? |□ |□ |
|Do you have a runny nose? |□ |□ |
|Have you recently lost or had a reduction in your sense of smell? |□ |□ |
|Do you have a sore throat? |□ |□ |
|Have you been in contact with someone who was tested positive for COVID-19? |□ |□ |
|Have you tested positive for COVID-19? |□ |□ |
|Have you been tested for COVID-19 and are awaiting results? |□ |□ |
|Have you traveled outside the State or the Country in the last 4 weeks? |□ |□ |
|Have you traveled outside the United States by air or cruise ship in the last 2 weeks |□ |□ |
|Have you traveled within the United States by air, bus or train within 2 weeks |□ |□ |
| | | |
|In the past 14 days, have you or any household member travelled to International area (China, Iran, Italy, Japan, |□ |□ |
|South Korea and / or European countries) | | |
|Does any household member, works in hospital, rehab, nursing home or other medical facilities? If so, where? |□ |□ |
|________________________________________ | | |
I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system. By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Signature ________________________________ Date ______________________________
................
................
In order to avoid copyright disputes, this page is only a partial summary.
To fulfill the demand for quickly locating and searching documents.
It is intelligent file search solution for home and business.
Related download
- patient information
- form completion human resources
- tactical triage operational medicine
- driver s application for employment
- health and human services acquisition regulation
- pandemic influenza electronic exercise tool
- northern syracuse ob gyn associates m
- national council of certified dementia practitioner llc
Related searches
- fluzone patient information sheet
- new patient information template
- new patient information form template
- new patient information form
- new patient information sheet template
- free printable patient information sheet
- patient information form template
- patient information template
- printable new patient information form
- patient demographic information form
- achilles tendonitis patient information pdf
- new patient information form pdf