Patient Information



New Patient InformationDr. James LutonskyWelcome to our practice!Please take your time to fill out this form completely. The more we learn about you, the better care we are able to provide. We are excited to work with you in building/maintaining a beautiful and healthy smile to last you a lifetime!Patient InformationToday’s Date: Name: Nickname□Male□FemaleAddress Apt/Ste # City State ZipDriver license # Date of Birth (Month/Day/Year) / / Social Security # - - Home Phone - - Cell - - Work Phone - - E-mail Primary contact: □Home □Cell □Work □E-mailEmployerMarital Status: □Married □Single □Divorced □WidowedWhom may we thank for referring you? Person to contact in case of an emergency:Name Relationship # Dental HistoryReason for Today’s Visit Are you currently in pain or having dental problems? □ No□ Yes: * Please describe: Have you ever had trouble with previous dental treatment? □ No□ Yes *Please describe: Level of anxiety about seeing the dentist:(Least) 1 2 3 4 5 (Most)Date of: Last dental exam _ Last Cleaning Last full mouth x-rays Previous dentist name Why are you changing dentists? What other dental aids do you use? (Electronic toothbrush, waterpick, etc.) Do you require antibiotics before dental treatment?□ Yes □ NoDo you have frequent headaches?□ Yes □ NoDo your gums ever bleed?□ Yes □ NoDo you clench or grind your teeth?□ Yes □ NoHave you noticed any mouth odors or bad tastes?□ Yes □ NoAre your teeth sensitive?□ Yes □ NoDo you bite your lips?□ Yes □ NoDo you still have your wisdom teeth?□ Yes □ NoHave you ever had:Periodontal disease/gum treatment□ Yes □ NoDiscomfort in your jaw joint□ Yes □ NoOrthodontic treatment□ Yes □ NoA night guard□ Yes □ NoSerious injury to the mouth or head□ Yes □ NoOral surgery□ Yes □ NoIs there anything else about your past dental treatment(s) that you would like us to know? Medical HistoryHave you been hospitalized or under the care of a medical doctor during the past 2 years?□ Yes □ No If yes, for what? Hospital or Physician’s name Phone Are you currently taking any medications or drugs?□ Yes □ No If yes, Please list all Have you been to the doctor to check for heart problems?□ Yes □ No If so, what are the problems? Do you use tobacco? □ Yes □ No Do you use alcohol or any other controlled substances? □ Yes □ No Women only: Are you taking birth control pills? □ Yes □ NoAre you nursing?□ Yes □ No Are you pregnant or think you might be pregnant? □ Yes □ NoIndicate which of the following you have had or have present:AIDS/HIV Positive□Y □NCancer□Y □NHeart Attack□Y □NLung Disease□Y □NAlzheimer's Disease□Y □NChemotherapy□Y □NHeart Pace Maker□Y □NMitral Valve Prolapse□Y □NAnaphylaxis□Y □NCold Sores□Y □NHeart Trouble□Y □NParathyroidDisease□Y □NArthritis□Y □NCortisone Medicine□Y □NHemophilia□Y □NPsychiatric Care□Y □NArtificial Heart Valve□Y □NDiabetes□Y □NHepatitis A, B or C□Y □NOsteoporosis□Y □NArtificial Joint□Y □NEmphysema□Y □NHigh Blood Pressure□Y □NRenal Dialysis□Y □NAsthma□Y □NEpilepsy/Seizures□Y □NHypoglycemia□Y □NRheumatism□Y □NBlood Disease□Y □NExcessive Bleeding□Y □NKidney Problems□Y □NSpina Bifida□Y □NBlood Thinner□Y □NFainting Spells□Y □NLiver Disease□Y □NStroke□Y □NBruise Easily□Y □NFrequent Cough□Y □NLow Blood Pressure□Y □NThyroid Disease□Y □NPlease List any serious medical condition (s) that you have ever had not listed above: Are you aware of having an allergic (or adverse) reaction to any of the following:Codeine□ Yes □ NoLatex□ Yes □ NoPenicillin□ Yes □ NoErythromycin□ Yes □ NoOther: 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 Date Primary Carrier:Dental InsuranceInsurance co. name Phone #: ( ) - Group # Member ID Policy # Insured’s name Relationship to patient DOB Social Security # Insured’s employer name Is Insured a patient in our practice? □ Y □ NPerson Financially Responsible for Account: (If someone other than patient)First Name: Last Name: □Male □FemaleAddress Apt/Ste # City State Zip Date of Birth (Month/Day/Year) / / Social Security # - - Driver license # Phone # □□Written Financial Policy□□Patients with Dental Insurance: We are a NON participating provider with all PPO insurance plans. We are happy to work with your carrier to maximize your benefits and directly bill them for reimbursement. An estimated patient portion will be due at the time of service. You will be asked to register a valid credit card for the application of any remaining balance.1Payment Options:You can choose from:Cash, Check, Visa, MasterCard, American Express or Discover CardConvenient Monthly Payment Options2 from CareCredit Healthcare Credit Card- Allows you to pay overtime and no annual fees or pre-payment penaltiesWe offer a 10% courtesy accounting adjustment to patients who pay for their treatment with cash or check prior to completion of care for treatment plans of $1500 or more. **Certain exclusions apply.Please note:We requires payment at the beginning of your treatment.For larger, more comprehensive treatment plans of $1000 or more, a 25% deposit is required to secure your initial treatment appointment.A fee of $70 is charged for patients who miss or cancel more than 3 times in a calendar year without 24-hour notice.Any account over 30 days past due will be assigned to collections and an additional $25 charge will occur.I have read and understand all the above and I acknowledge that I am ultimately responsible for all fees incurred. Patient/Guardian Name (Printed): Signature: Date: 1 However, if we do not receive payment from your insurance carrier within 60 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.2 Subject to credit approvalOFFICE USE ONLY: I verbally reviewed the medical and dental information with this patient.DATE PRINTED NAME □□ HIPAA CONSENT FORM □□Dr. James LutonskyPATIENT GIVING CONSENT:Name: Date:_ TO THE PATIENT:Purpose of Consent: By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, and health care options.Right to Revoke: You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).The Patient Understands that:Protected health information may be disclosed or used for treatment, payment, or healthcare operations.The Practice has a Notice of Privacy Practices and the patient has the opportunity to review this Notice.The Practice reserves the right to change the Notice of Privacy Practices.The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.The patient may revoke this Consent in writing at any time and all future disclosures will then cease.The practice may condition receipt of treatment upon the execution of this Consent.I have had full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practice. I understand that by signing below, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activity, and healthcare options.SignatureDateAgreement to Receive Electronic CommunicationI agree that the dental practice may communicate with me electronically at the email address below.I am aware that there is some level of risk that third parties might be able to read unencrypted emails.I am responsible for providing the dental practice any updates to my email address.Email: @ Signature: Date: ................
................

In order to avoid copyright disputes, this page is only a partial summary.

Google Online Preview   Download