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-5524500 Santa Rosa Dental Healthy Smiles For Your Healthy Lifestyle Medical History66484502286000Patient Last __________________ First __________________ MI ____ Age _____ DOB ___/___/___ Job ______________________Address _______________________________________ Apt ____ City ________________________ Zip code __________________Phone (Home): ______________ (Cell) ________________ (Work) _______________ e-mail: ___________________________________Person to contact in case of Emergency ______________________________ Phone _________________ Relationship _______________Last physical examination ___/___/____ Purpose _______________ Physician’s Name ___________________ Phone_________________1.A bad experience in the dental office?22.Liver disease2.Any allergic reaction to:23.Thyroid, parathyroid disease, or calcium deficiencyAspirin, Ibuprofen, codeine24.Hormone deficiencyPenicillin25.High cholesterol or taking statin drugsErythromycin26.Diabetes (HbA1c= ______)Local Anesthetic27.Stomach or duodenal ulcerFluoride28.Digestive disorders (i.e. Gastric Reflux)Metal(Nickel, Gold, Silver)29.Osteoporosis/osteopenia(i.e. Taking Biophosphonates)Latex30.Arthritis3.Hospitalization for illness or injury31.Glaucoma4.Heart problems, heart attack or cardiac stent for the last 6months32.Contact Lenses5.History of infective endocarditic33.Head or neck injuries6.Artificial heart valve34.Epilepsy, convulsions(seizures)7.Pacemaker or implantable defibrillator35.Neurologic problems (attention deficit disorders)8.Artificial prosthesis (heart valve or joints)36.Viral infections and cold sores9.Rheumatic or scarlet fever37.Any lumps or swelling in the mouth10.Angina Pectoris38.Hives, skin rash, hay fever11.Heart Murmur39.HIV/AIDS12.High or low blood pressure40.Hepatitis A (infectious)13.Stroke (Taking blood thinners)41.Hepatitis B (Serum)14.Anemia or other blood disorders42.Tumor abnormal growth15.Prolonged bleeding due to light cut (INR > 3.5)43.Radiation therapy16.Blood Transfusion44.Chemotherapy17.Emphysema, sarcoidosis45.Emotional problems18.Tuberculosis46.Psychiatric treatment19.Asthma47.Antidepressant medication20.Breathing or sleeping problems (i.e. snoring, sinus)48.Alcohol/drug dependency21.Kidney disease49.Cortisone Medicine600075026035YES00YES632460026035NO00NO-42862526035DO YOU HAVE or HAVE YOU EVER HAD00DO YOU HAVE or HAVE YOU EVER HAD243840026035YES00YES276225026035NO00NO50. Are you having any concern, discomfort or pain at this time?.............................................................................................................................. YES NO51. Do you feel very nervous about having dental treatment?.................................................................................................................................. YES NO52. When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest or shortness of breath, or because you are very tired?....................................................................................................................................... YES NO53. Do your ankles swell up during the day?............................................................................................................................................................... YES NO54. Do you use more the two pillows to sleep?........................................................................................................................................................... YES NO55. Have you lost or gained ten pounds in the past year?........................................................................................................................................... YES NO56. Do you ever wake up from sleep short of breath?................................................................................................................................................ YES NO57. Are you on special diet?......................................................................................................................................................................................... YES NO58. Are you taking medication for weight control (i.e. fen-phen)…………………………………………………………………………………………………………………………. YES NO59. Are you a smoker or smoked previously, if yes how many cigarettes/cigars a day for how long?....................................................................... YES NO60. Has your medical doctor ever said you had cancer or tumor?.............................................................................................................................. YES NO61. Do you have any disease, condition, or problem not listed?................................................................................................................................ YES NO62. Women:Are you pregnant now?.......................................................................................................................................... YES NOAre you practicing birth control?............................................................................................................................ YES NODo you anticipate becoming pregnant?.................................................................................................................. YES NO63. What is your estimated of your general health:ExcellentGoodFairPoor64. Whom may we thank for referring you to our practice?-704850111760To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health, or if my medicines change, I will inform the doctor of dentistry at the next appointment without fail.00To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health, or if my medicines change, I will inform the doctor of dentistry at the next appointment without fail. Dental Office Yellow Pages Newspaper School Work Other __________________512445070485________________ Date00________________ Date210502570485____________________________________Signature of patient, parent of guardian00____________________________________Signature of patient, parent of guardian-56197570485________________________________ Dr. Signature00________________________________ Dr. Signature PHYSICAL / PSYCHOLOGICAL EVALUTION BP: ________ Weight: _______ Height: ______ Pulse: ______ Resp:______ Temp: _______Current Medical Problems:3. Current Medications:________________________________________________________ a. ______________________________________________________________________________________________________________ b. ________________________________________-60960080010YesNo ___________________________________________Date _____________________00YesNo ___________________________________________Date _____________________Referral:General Comments: ____________________________________________________________________________________________________________________________________________________________________________________________________________4038600141605________________________________ Dr. Signature00________________________________ Dr. SignatureASA:IIIIIIIV-3479803423920________________ Date00________________ Date11811003423920_________________________________________________________________________________ Signature of Insured / Guardian00_________________________________________________________________________________ Signature of Insured / Guardian11144252490470_________________________________________________________________________________ Signature of Insured / Guardian00_________________________________________________________________________________ Signature of Insured / Guardian-3479801309370________________ Date00________________ Date11144251356995_________________________________________________________________________________Signature00_________________________________________________________________________________Signature-3479802433320________________ Date00________________ Date-523875261620ASSIGMENT AND RELEASEI, the undersigned, have insurance with _______________________________________________________________________________________ Name of Insurance Company (ies)and assign directly to Dr. ______________________ all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment benefit. I authorize the use of this signature on all my insurance submission whether manual or electronic.MINOR / CHILD CONSENTI, being the parent or guardian of _____________________________________________________________________ do hereby request and Name of Minor / ChildAuthorize the dental staff to perform necessary dental services for my child, including but not limited to X-rays, and administration of anesthetics which are deemed advisable by the doctor, whether or not I am present at the actual appointment when the treatment is rendered.FINANCIAL AGREEMENTI acknowledge that payment is due to the time of treatment, unless other arrangements are made. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor/child. I accepted full financial responsibility for all chargers not covered by insurance.00ASSIGMENT AND RELEASEI, the undersigned, have insurance with _______________________________________________________________________________________ Name of Insurance Company (ies)and assign directly to Dr. ______________________ all benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment benefit. I authorize the use of this signature on all my insurance submission whether manual or electronic.MINOR / CHILD CONSENTI, being the parent or guardian of _____________________________________________________________________ do hereby request and Name of Minor / ChildAuthorize the dental staff to perform necessary dental services for my child, including but not limited to X-rays, and administration of anesthetics which are deemed advisable by the doctor, whether or not I am present at the actual appointment when the treatment is rendered.FINANCIAL AGREEMENTI acknowledge that payment is due to the time of treatment, unless other arrangements are made. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor/child. I accepted full financial responsibility for all chargers not covered by insurance.-5524500 Santa Rosa Dental Healthy Smiles For Your Healthy Lifestyle Notice of Privacy Practices AcknowledgementI understand that, under the Health Insurance Portability & Account Act of 1996 ( “HIPPA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:Conduct, Plan, and direct my treatment and follow up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.Obtain payment from third party payers.Conduct normal healthcare operations such as quality assessments and physician certifications.I acknowledge that I have received your Nonce of Private Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Nonce of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Nonce of Privacy Practices.I understand that I may request in writing that you may restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree with my requested restrictions, but if you do agree then you are bound to abide by such restrictions.Patient Name _____________________________________________________Relationship to Patient _____________________________________________________Signature _____________________________________________________Date ___________________________________________________-5524500 Santa Rosa Dental Healthy Smiles For Your Healthy Lifestyle ____________________________________ Name of PatientPATIENT CONSENT TO TREATMENTIn reading and signing this form it is understood that English is the language that I understand and use to communicate. (Initials)_________[ ] 1. DRUGS, MEDICATIONS, AND ANESTHESIA: I understand that antibiotics, analgesics, and other medications may cause adverse reactions, some of which are but are not limited to redness and swelling of tissues, pain, itching, vomiting, vomiting, dizziness, miscarriage, cardiac arrest I understand that medications, drugs, and anesthetics may cause drowsiness and lack of coordination which can be increased by the use of alcohol or other drugs. I have been advised not to consume alcohol, nor operate any vehicle or hazardous device while taking medications and /or drugs, or until fully recovered from their effects (this includes a period of at least twenty-four [24] hours after my release from surgery) I understand that occasionally, upon injection of a local anesthetic. I may have prolonged, persistent anesthesia, numbness, and/or irritation to the area of injection. I understand that if I select to utilize Nitrous Oxide. Atarax. Chloryl hydrate. Zanax or any other sedative possible risk include, but are not limited to, loss of consciousness, obstruction of airway, anaphylactic shock, cardiac arrest. I understand that someone needs to drive me home from the dental office after I have received sedation. I also understand that someone needs to watch me closely for a period of 8 to 10 hours, following my dental appointment to observe for possible deleterious side effects, such as obstruction of airway. (Initials)__________ [ ] 2. HYGIENE AND PERIODONTCS (TISSUE AND BONE LOSS): I understand that the long term success of treatment and status of my oral condition depends on my efforts at proper oral hygiene (i.c brushing and flossing and maintaining regular recall visits. PERIODONTICS- I understand that I have a serious condition causing gum and bone inflammation and/ or loss, and that it can lead to loss of my teeth and other complications. The various treatment plans have been explained to me, including gum surgery, replacement and /or extractions. I also understand that although these treatments have a high degree of success, they cannot be guaranteed. Occasionally, treated teeth may require extraction. (Initials)___________ [ ] 3. REMOVAL OF TEETH: I understand that the purpose of the procedure/surgery is to treat and possibly correct my diseased oral tissues. The doctor has advised me that if this condition persists without treatment or surgery. My present oral condition will probably worsen in time. Potential risks include, but are not limited to, the following:Post-operative discomfort, swelling, prolonged bleeding, tooth sensitivity to hot or cold, gum shrinkage (possibly exposing crown margins); tooth looseness, delayed healing (dry-socket) and/or infection (requiring prescriptions or additional treatment, i.e. surgery)Injury to adjacent teeth, caps, or fillings (requiring the recommendation of crowns, replacement of fillings, fabrication of crowns, or extraction), or injury to other tissues not within the described surgical areaLimitation of opening, stiffness of facial and/or neck muscles, change in bite, or temporomandibular joint (jaw joint) difficulty (possibly requiring physical therapy or surgery)Residual root fragments or bone spicules left when complete removal would require extensive surgery or needless surgical complicationsPossible bone fracture which may require wiring or surgical treatmentOpening of the sinus (a normal cavity situated above the upper teeth) requiring additional surgeryInjury to the nerve underlying the teeth result in itching, numbness, or burning of the lip, chin, gums, cheek, teeth, and0or tongue on the operated side, this may persist for several weeks, months, or in remote instances, permanently.I give my consent for the doctor to perform the treatment/procedure/surgery previously explained to me, or other procedures deemed necessary or advisable as necessary to complete the planned operation.If any unforeseen condition should arise in the course of the operation, calling for the doctor’s judgment or for procedures in addition to or different from those now contemplated, I request and authorize the doctor to do whatever (s)he may deem advisable, including referral to another dentist or specialist. I also understand that the cost of this referral would be my responsibility. (Initials)____________[ ] 4. FILLINGS:I have been advised of the need for fillings, either silver or composite (plastic), to replace tooth structure lost to decay. I understand that with time fillings will need to be replaced due to wearing of material. In cases where very little tooth structure remains, or existing tooth structure fractures off, I may need to receive more extensive treatment (such as root canal therapy, post and build-up, and crowns), which would necessitate a separate charge.I understand that the silver amalgam restoration is an acceptable procedure according to the American Dental Association guidelines and, as such, is a treatment used by SANTA ROSA DENTAL. The advantages and disadvantages of alternate materials have been explained to me.[ ] 5. ENDODONTIC TREATMENT (ROOT CANAL THERAPY):The purpose and method of root canal therapy have been explained to me, as well as reasonable alternative treatments, and the consequences of non-treatment. I understand that following root canal therapy my tooth will be brittle and must be protected against fracture by placement of a crown (cap) over the tooth.I understand that treatment risks can include, but are not limited to the following:Post treatment discomfort lasting a few hours to several days for which medication will be prescribed if deemed necessary by the doctor.Post treatment swelling of the gum area in the vicinity of the treated tooth or facial swelling, either of which may persist for several days or longer.InfectionRestricted jaw opening.Breakage of root canal instruments during treatment, which may in the judgment of the doctor be left in the treated root canal or bone as part of the filling material, or it may require surgery for removal.Perforation of the root canal with instrument, which may require additional surgical treatment or result in premature tooth loss or extraction. Risk of temporary or permanent numbness in treatment area. (Initials)_____________ [ ] 6. CROWN AND BRIDGE (CAPS): I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I understand that at times, during the preparation of a tooth for a crown, pulp exposure may occur, necessitating possible root canal therapy. I understand that like natural teeth, crowns and bridges need to be kept clean, with proper oral hygiene and periodic cleaning, otherwise may develop underneath and/or around the margins of the restoration, leading to further dental treatment. (Initials)______________[ ] 7. DENTURES – COMPLETE OR PARTIAL: The problems of wearing dentures have been explained to me including looseness and possible breakage and relining due to tissue change. Follow- up appointments are an integral part of maintenance and success of a prosthetic appliance persistent sore spots should be immediately examined by examined by the doctor. I further understand that surgical intervention (i.e. tori [bone] removal, bone re-contouring, or implants) may be needed for dentures to be properly fitted. I also understand that due to the bone loss or other complicating factors, I may never be able to wear dentures to my satisfaction. (Initials)_______________ [ ] 8. PEDODONTICS (CHILD DENTISTRY): I understand that the following procedures are routinely used at SANTA ROSA DENTAL as well as being accepted procedures in the dental profession. POSITIVE REINFORCEMENT- Re-warning the child who portrays desirable behavior, by use of compliment, praise, a pat or hug, and or token objects or toys. VOICE CONTROL- The attention of a disruptive child is gained by changing the tone or increasing the volume of the doctor’s voice. PHYSICAL RESTRAINT- Restraining the Childs disruptive movements by holding down their hands, upper body, head, and or legs by use of the dentists or assistants hand or arm or by use of a special device (referred to as a papoose board).NITROUS OXIDE AND/OR ORAL SEDATION- Nitrous Oxide is a mild gas that is mixed with oxygen, and is used to sedate a person. It is administered through a mask place over the Childs nose. Oral sedations are medications administered to children to help them relax. With their use the parent/or guardian must that the child should not eat or drink for a period of four hours prior to the sedation appointment. The parent/guardian must be available to escort the child home after the sedation, and observe their behavior throughout the day.I understand that with the use of an injection, used to numb the tooth for dental procedures, the possibility exists that the child may inadvertently bite their lip causing to occur. I understand the need to the office, for evaluation if swelling and/or pain in my child does not go away after a sufficient period of time. I understand the need to return to the office within three months following nerve nerve treatment of a “baby tooth “for evaluation, and the possibility of it then needing an extraction. (Initials)_______________I UNDERSTAND THAT NO GUARNTEE OR ASSURANCE HAS BEEN GIVEN THAT THE PROPOSED TREATMENT WILL BE CURATIVE AND/OR SUCCESSFUL TO MY COMLETE SATISFACTION. I AGREE TO CO-OPERATE COMLETELY AND COMPLELY WITH THE RECOMMENDATIONS OF THE DOCTOR OF THE DOCTOR WHILE I AM UNDER HER/HIS CARE, REALZING THAT ANY LACK OF SAME COULD RESULT IN LESS TAN OPTIMUM RESULTS. I CERTIFY THAT I HAVE AN OPPORTUNTY TO READ TO FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE, INCLUDING THE OPPOSING SIDE THIS DOCUMENT, AND CONSENT TO THE OPERATION AND EXPLANATION REFERRED TO OR MADE. I HAVE BEEN ENCOURAGED TO ASK QUESTIONS, AND HAVE HAD THEM ANSWERED TO MY SATISFACTION. I UNDERSTAND THAT SANTA ROSA DENTAL PROVIDES DENTAL CARE SERVICES WITHOUT DISCIMINATION BASED ON RACE, RELIGION, COLOR, NATIONAL ORIGIN, SEX SEXUAL ORIENTATION, PHYSICAL OR MENTAL DISABILITY, AGE MARITAL STATUS AND PROTECTS THE PRIVACT OF EACH OF ITS PATIENTS. Signature:_________________________________________Relationship:____________________Date:___/____/________ Patient or Legal RepresentativeDoctor:__________________________________________________Witness____________________________________________ ................
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