ProSites, Inc.
Date: ___________________Patient Name (First/Last): _________________________________ Preferred: _____________________ Gender: Male Female Family Status: Single Married Child OtherDate of Birth: __________________ SS#: ___________________ Email: ______________________Phone: ____________________ ________________ _________ _______________________ Home Work Ext Mobile Address: _________________________________________________________________________________ Street Apartment/Unit# ___________________ ________ ________________ City State Zip CodeWhom may we thank for referring you to our practice? How did you hear about us?__________________________________________________________________________________________________Emergency Contact: _________________________ ___________________ _____________________ Name Relationship Phone #Employer Name: _________________________________ Phone: _____________________Address: _________________________________________________________________________________ Street City State Zip CodeResponsible Party Information: This only needs to be filled out if the insurance subscriber is other than patient, or are you the parent/guardian of the patient. The following is for: Patient’s Spouse Person Responsible for Payment Name (First/Last): ___________________________________ Preferred: ________________________ Gender: Male Female Family Status: Single Married Child OtherDate of Birth: __________________ SS#: ___________________ Email: _________________________Phone: ____________________ ________________ _________ _______________________ Home Work Ext Mobile Address: _________________________________________________________________________________ Street Apartment/Unit# ___________________ ________ ________________ City State Zip CodeWho is accompanying the child today? ____________________________ ___________________ Name Relationship Do you have legal custody of the Child? Yes NoPrimary Dental Insurance:Name of Subscriber (First/Last): ____________________________ Date of Birth: ________________Primary Insurance Plan Name: ______________________________Subscriber ID#: ______________________________ Group#: ______________________Insurance Address: ___________________________________________________________________ Insurance Company Phone#____________________________________Patient’s Relationship to Subscriber: Self Spouse Child OtherSecondary Dental Insurance: Name of Subscriber (First/Last): ____________________________ Date of Birth: ________________Primary Insurance Plan Name: ______________________________Subscriber ID#: ______________________________ Group#: ______________________Insurance Address: ___________________________________________________________________ Insurance Company Phone#____________________________________Patient’s Relationship to Subscriber: Self Spouse Child OtherInsurance Authorization: By checking this box, I authorize my insurance company to pay the dentist all insurance benefits rendered. I authorize the use of this electronic signature on all insurance submissions. I authorize the dentist(s) to release all information necessary to secure the payment of benefits. I understand that I am financially responsible for all charges whether or not paid by insurance. Dental InformationWhat is your immediate concern?__________________________________________________________________________________________How would you rate the condition of your mouth? Excellent Good Fair PoorPrevious Dentist Name and Phone number:__________________________________________________________________________________________Why did you leave your last dental office?__________________________________________________________________________________________Date of most recent dental exam and x-rays: ________________________________Is there anything about the appearance of your smile that you would like to change?__________________________________________________________________________________________Check all that apply: Had complications from past dental treatment Fearful or anxious going to the dentist Had trouble getting numb Had any reactions to local anesthetic Gags easily Cold sores/fever blisters Had/have braces, orthodontic treatment You experience dry mouth Any teeth sensitive to hot, cold, biting, sweets, or avoiding brushing any part of your mouth Food gets trapped between any teeth Have you ever whitened or bleached your teeth Have you experienced popping and/or clicking of your jaw joint Have you experienced jaw locking/muscle fatigue You have difficulty chewing or swallowing You clench or grind your teeth You wear or have worn a bite appliance Have frequent headaches Have frequent neck or back pain Gums bleed when brushing or flossing Treated for gum disease or were told you have lost bone around your teeth Noticed an unpleasant taste or odor in your mouth Experienced gum recession Had any teeth become loose on their own (without injury) You snore or wake up frequently during the nighFor Children:Thumb sucking/Lip sucking: Yes NoNursing/Bottle habits: Yes NoTonsils or Adenoids removed: Yes NoMouth breather: Yes NoIf any of the checked boxes need further explanation, please describe:______________________________________________________________________________________Consent for Services and Financial Policy I authorize the dentist and/or staff to take x-rays, models, photographs, and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis and upon such diagnosis, I authorize the recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper Care. _____ InitialI understand that the photographs, slides, and/or x-rays may be used for educational purposes in lectures, demonstrations, advertising (including website publication), and professional publications (dental magazine and journals). I further understand that if the photographs, slides, and/or x-rays are used in any publication or as a part of a demonstration, my name or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these photographs. ______ InitialAppointment Guidelines: A portion of the fee for services will be collected at the time treatment is scheduled. The amount paid will be applied towards your patient portion for services provided. If you need to change your appointment, kindly give at least 48 hours notice. If an appointment is cancelled without 48 hours notice, the reservation fee will be forfeited and an additional $30 per half hour would be required to make a new appointment. *Failure to show for an appointment without any notice may result in dismissal from the practice for yourself and immediate family. ______ InitialDental Insurance:Insurance coverage is a contract between you, your employer, and your insurance company. As we are not representatives of your insurance company, any insurance estimates discussed are estimates only and are not a guarantee of payment. This office will help prepare your insurance forms or assist in making collections from insurance companies and will credit any such collections to your account. *I agree to inform the office if there are any changes to my insurance coverage. ______ InitialI understand that all dental services furnished by this office are charged directly to me and that I am personally responsible for payment of all dental services. I also understand I am responsible for paying all charges not covered by my insurance company, including all fees above what the insurance calls “usual and customary”. ______ InitialFinancial Policies:I understand that checks that are returned unpaid are subject to a $35.00 fee. In consideration for the professional services rendered to me by Kailua Dental Arts staff, I agree to pay the reasonable value of said services to the practice at the same time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition. I further agree to pay all costs and reasonable attorney fees if suit were instated hereunder. ______ InitialHawaii charges a 4.712% tax for medical and dental services. By law, we are required to collect this for the state. ______ Initial________________________________________________ _____________________ Printed Name of Patient Date______________________________________________________ _______________________________ Signature of Patient (if patient is a minor, the parent, or guardian) Relationship to Patient______________________________________________________ ________________________________ Signature of Guarantor accepting financial responsibility for account Relationship to PatientHIPAA ACKNOWLEDGEMENT I understand that I may inspect or copy the protected health information described by this authorization. I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form. I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality. ________________________________________________ _____________________ Printed Name of Patient Date _______________________________________________ _______________________________ Signature of Patient (if patient is a minor, the parent, or guardian) Relationship to PatientMEDICAL HISTORYPatient Name (First/Last): ________________________________ DOB: _____________________Indicate which of the following conditions you have or have had. By checking the box, it will indicate a “YES” response, leaving it blank will indicate a “NO” response.___ ADHD ___ Allergy-Seasonal ___ Allergy Anesthetic___ Allergy Aspirin ___ Allergy Codeine ___ Allergy Erythromycin___ Allergy Hydrocodone ___ Allergy Ibuprofen ___ Allergy Keflex___ Allergy Latex ___ Allergy NSAIDS ___ Allergy Other__________ Allergy Penicillin ___ Allergy Peridex ___ Allergy Sulfa___ Allergy Tetracycline ___ Anemia ___ Angina___ Antibiotic Premed ___ Anxiety ___ Arthritis___ Artif. Heart Valve ___ Artificial Joints ___ Asthma___ Blood Disease ___ Blood Thinners ___ Cancer___ Currently Pregnant ___ Diabetes ___ Dizziness/Fainting___ Epilepsy ___ Excessive Bleeding ___ Head Injury___ Hearing Impaired ___ Heart Defect ___ Heart Disease___ Hepatitis ___ High Blood Pressure ___ Insulin Pump___ Jaundice ___ Kidney Disease ___ Liver Disease___ Mental Disorders ___ Osteoporosis Meds ___ Other___ Pacemaker ___ Radiation Treatment ___ Recreational Drugs___ Respiratory Problems ___ Stomach Problems ___ Stroke___ Thyroid Condition ___ Tobacco Use ___ Tuberculosis___ Tumors ___ Ulcers Ever been hospitalized (illness or injury) in the past 2 years, if yes, please explain below Presently being treated for any other illnesses, if yes, please explain below FEMALE: Pregnant or Breastfeeding FEMALE: Taking birth control pills, I understand taking antibiotics may render oral contraceptive ineffective By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes. If any conditions or alerts selected above need further clarification, please describe below:____________________________________________________________________________________________________________________________________________________________________________________________________Do you take antibiotic premedication for your dental visits? If Yes, please explain.____________________________________________________________________________________________________________________________________________________________________________________Name of your physician and contact number: __________________________________________________________________________________________Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment.____________________________________________________________________________________________________________________________________________________________________________________List all medications (prescription, non-prescription, supplements, herbal remedies) including regular doses of aspirin: ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ ________________________________________________ _____________________ Printed Name of Patient Date __________________________________________________ _________________________Signature of Patient (if patient is a minor, the parent, or guardian) Relationship to Patient ................
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