Verfiy Patient Information - Heber City Dentist



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PATIENT INFORMATION SHEET

Date: Referred By:________________________________

Patient’s Name: SSN: Birthdate:___________

Age: Address: City/ST/Zip:__________________

Home Phone #:__________________________ Cell #________________________________Sex: M F

Marital Status: M S W D Email:____________________________________________

Employer: Work Phone:__________________________

Occupation: ___________________________ Emergency Contact Person ________________________

Relationship:__________________________ Emergency Contact Phone_________________________

Do you have insurance? Y ☐ N ☐

Insurance Co_________________________________ Member ID#__________________________

DENTAL HISTORY

Date of last dental visit Reason for today’s visit

How often do you brush? Floss? Do you authorize your child to receive fluoride? Y ☐ N ☐

Have you ever experienced an adverse reaction during or in conjunction with anesthesia or a medical

procedure? Y ☐ N ☐

Do you have an allergy to latex? Y ☐ N ☐

Other information about your dental health or previous treatment.

Have you had problems with any of the following?

If none of these apply, please check here: ☐

☐ Bad breath ☐ Food collection between teeth ☐ Periodontal treatment

☐ Bleeding gums ☐ Grinding or clenching teeth ☐ Sensitivity to biting

☐ Sores/growths in mouth ☐ Sensitivity to sweets ☐ Sensitivity to hot/cold

☐ Clicking or popping jaw ☐ Loose teeth or broken fillings OTHER:

MEDICAL HISTORY

Physician’s name Date of last visit

Are you currently under a physician’s care? ☐Y ☐N

If yes, please describe _

In the past two years, have you been admitted to a hospital or needed emergency care? ☐Y ☐N

If yes, give approximate date and explain

Have you ever had any complications following dental treatment? ☐Y ☐N

If yes, please explain

Women: Are you pregnant? ☐Y ☐N Nursing? ☐Y ☐N Taking birth control pill? ☐Y ☐N

Is patient currently taking any medications? ☐Y ☐N If yes, list all in the space below.

Does patient have any drug allergies? ☐Y ☐N If yes, please list medications and the allergic reaction.

Does patient have any allergy to anesthetic or epinephrine? ☐Y ☐N

If you have ever had any of the following conditions, please check:

If none of these apply, check here: ☐

☐ AIDS/HIV Positive ☐ Psychiatric Care ☐ Heart surgery ☐ Anemia

☐ Glaucoma ☐ Arthritis/ Rheumatism ☐ Respiratory disease ☐ Heart murmur

☐ Rheumatic fever ☐ Artificial joints ☐ Heart problems ☐ Shingles

☐ Asthma ☐ Shortness of breath ☐ Atopic/ Allergy prone ☐ Skin rash

☐ Hemophilia/bleeding ☐ Herpes ☐ Blood disease ☐ Hepatitis

☐ Stroke ☐ Cancer ☐ High blood pressure ☐ Jaw pain

☐ Chemotherapy ☐ Kidney disease ☐ Thyroid problems ☐ Liver disease

☐ Tobacco habit ☐ Circulatory Disease ☐ Material allergies ☐ Tonsillitis

☐ Tuberculosis ☐ Mitral valve prolapse ☐ Ulcer/ Colitis ☐ Diabetes

☐ Nervous problems ☐ Epilepsy ☐ Other- please describe:

I have reviewed the information on this questionnaire, and it is accurate to the best of my knowledge. I understand that this information will be used by the dentist to help determine appropriate dental treatment. If there is any change in my medical status, I will inform the dentist. I consent to have TimberRidge Dental provide me with dental treatment.

Signature of Patient: Date

Notice of HIPAA Privacy Practices

We will only use your private information to provide treatment and to procure payment. This means that we may need to share your information with another office providing specialty care for you, your insurance, or with our electronic billing service. We will not share your information with anyone else without your permission.

A copy of this office’s Privacy Practices has been made available.

Signature_________________________________________ Date_______________________

I authorize the following person(s) to have access to information covered under the Privacy Practice regarding my care.

Please print name__________________________________ Relationship_________________

CANCELLATION POLICY

We reserve your appointment time just for you, and we require a minimum of 24 hour notice to change an appointment. All appointment changes must be made on the phone during regular office hours (Monday-Thursday, 8-6), as our text and voicemail are not monitored for schedule changes.

Cancellations without a 24-hour notice are subject to a $50 charge.

Initials:

FINANCIAL POLICY

By signing below, I agree to pay all amount(s) owed within 30 days of when such amount(s) are incurred. I understand that it is my responsibility to provide my correct/ updated insurance information and that this office will bill my insurance as a courtesy to me. However, regardless of insurance coverage, I agree that it is and shall remain my responsibility to pay all amounts owing as set forth herein. I agree that interest will accrue on all past-due amounts at the rate of 18% per annum (1.5% per month) until paid in full. In the event any amount(s) is/are referred to a third-party debt collection agency, I agree that in addition to any other amount(s) allowed for by law, (such as interest, court costs, reasonable attorney’s fees, etc.) I will also be responsible for a collection fee of up to 40% of the principal amount(s) owing as allowed by Utah Code Annotated, sec.12-1-11. The terms of this paragraph shall apply to all amount(s) are incurred today or after today. I hereby consent to being contacted by telephone at any telephone number (including but not limited to wireless/ cellular phone numbers and/or email) provided by me or anyone associated with me or acting on my behalf to TimberRidge Dental or anyone acting on its behalf. Under H.B. 128 if any amount due is not paid by due date on statement or as agreed, TimberRidge Dental will report patient due amount to a collection agency that may affect the patients credit score. I authorize TimberRIdge Dental to share information given by myself for me or any of my children that I am guardian of, to any provider that I provide.

Signature of patient, parent, or guardian__________________________ Date __________________

Relationship to patient___________________________________

Acknowledgement of Receipt of

Notice of Privacy Practices

Patient information:

I, ________________________, acknowledge I have received a Notice of Privacy Practices from Tyler May, D.D.S.

Print name

Signature: _______________________________ Date: ____________________

Patient

Signature: ________________________________ Date: __________________

Parent or guardian

Relationship: _________________________

If you would like a copy of HIPPA disclosure, we will be happy to provide this for you.

CONSENT TO SHARE INFORMATION

I, give my consent for TimberRidge Dental to disclose my account information with the following person(s) who I have listed below.

1. - Relationship

2. -Relationship

3. -Relationship

4. -Relationship

I agree to disclose to TimberRidge Dental names of any individuals with whom I authorize the office to discuss my dental care. I authorize TimberRidge Dental to release information for treatment descriptions and information, either electronically, or paper form to my insurance or any related entities that require such information to be treated or submitted.

Signature of patient giving consent Date

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