FAMILY FIRST DENTAL OF COLUMBUS



DENTAL INNOVATIONS OF COLUMBUS

Kendra Pavlik DDS Michelle Bargen DDS

Date:_______________

Patient’s Information

Sex: οMale οFemale Marital Status: οMarried οSingle οDivorced οSeparated οWidowed

First Name:_________________________ Last Name:____________________ Middle Initial:_____ Preferred Name:__________

Mailing Address:_________________________________________City:___________________ State:_________ Zip:________

Home Phone: (_____)______-_________ Cellular: (_____)______-_________ Email:__________________________________

Birth Date:______/______/_______ Soc. Sec.: _______-______-_______Driver Lic #: ________________________

Student Status οFull Time οPart Time Name of School:__________________________ City:_______________ State:_____

Employment οFull Time οPart Time οRetired Name of Employer:____________________________ Phone #:_____________

Responsible for Account (If someone other than Patient) Sex: οMale οFemale

First Name:_________________________________ Last Name:_______________________________ Middle Initial:_______

Mailing Address:_________________________________________City:___________________ State:_________ Zip:________

Home Phone:______________________ Cellular:_____________________ Email:____________________________________

Birth Date:___________________________ Soc. Sec.: __________________________Driver Lic:________________________

Employer:___________________ Phone #: (_____)____________Marital Status: οMarried οSingle οDiv. οSeparated οWidowed

Emergency Contact Information (Family Member and Non Family Member)

Name:___________________________________ Relationship:______________________ Phone #: (______)______-______

Name:___________________________________ Relationship:______________________ Phone #: (______)______-______

Primary Dental Insurance Information

Sex: οMale οFemale Relationship of the Patient: οSelf οSpouse οChild οOther

Name of Insured:_______________________________ Birth Date:_____/_____/_____ Soc. Sec.: ______-_____-________

Employer________________________ Insurance Company:_____________________ ID Number:___________________

Secondary Dental Insurance Information

Sex: οMale οFemale Relationship of the Patient: οSelf οSpouse οChild οOther

Name of Insured:_______________________________ Birth Date:_____/_____/_____ Soc. Sec.: ______-_____-________

Employer________________________ Insurance Company:_____________________ ID Number:___________________

Other Information

Who may we Thank for Inviting you to our Practice? _____________________________________________________________

(Ex: Family, Friend, Phone Book, Social Media, On-Line Search, Billboard, Mailer, Newspaper, Radio, etc.)

Revised 05/2019

Medical History for _________________________

Although dental personal primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. If yes please use the following lines to answer.

Are you under a physician’s care now? οYes οNo-Name and # ____________________________________________

Have you ever been hospitalized or had a major operation? οYes οNo-Year and what for __________________________________

Have you ever had a serious head or neck injury? οYes οNo-Year and what for _______________________________________

|Med list: |

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Are you taking any medications, pills, or drugs? οYes οNo

Do you take, or have you taken, Phen-Fen or Redux?οYes οNo

Are you taking any medication for osteoporosis? οYes οNo

Are you taking any blood thinners? οYes οNo

Do you use tobacco? οYes οNo

Do you use controlled substances? οYes οNo

Do you vape? οYes οNo

Are you allergic to any of the following?

οAspirin οPenicillin οCodeine οAcrylic οMetal οLatex ο Sulfa Drugs ο Local Anesthetics

οOther Please Explain: __________________________________________________________________________

Women: Are you

Pregnant/Trying to get pregnant? οYes οNo Taking oral contraceptives? οYes οNo Nursing? οYes οNo

Sleep Screening

Do you snore? οYes οNo

Do you have unrefreshed sleep or fatigue? οYes οNo

Current CPAP user? οYes οNo

Are you CPAP intolerant? οYes οNo

Has someone noticed you stopped breathing? οYes οNo

Have you ever had a sleep study? οYes οNo

Do you have, or have you had any of the following?

AIDS/HIV Positive οYes οNo

Alzheimer’s Disease οYes οNo

Anaphylaxis οYes οNo

Anemia οYes οNo

Angina οYes οNo

Arthritis/Gout οYes οNo

Artificial Heart Valve οYes οNo

Artificial Joint οYes οNo

Asthma οYes οNo

Blood Disease οYes οNo

Blood Transfusion οYes οNo

Breathing Problem οYes οNo

Bruise Easily οYes οNo

Cancer οYes οNo

Chemotherapy οYes οNo

Chest Pains οYes οNo

Cold Sores/Fever Blisters οYes οNo

Congenital Heart Disorder οYes οNo

Convulsions οYes οNo

Cortisone Medicine οYes οNo

Diabetes οYes οNo

Drug Addiction οYes οNo

Easily Winded οYes οNo

Emphysema οYes οNo

Epilepsy or Seizures οYes οNo

Excessive Bleeding οYes οNo

Excessive Thirst οYes οNo

Fainting Spells/Dizziness οYes οNo

Frequent Cough οYes οNo

Frequent Diarrhea οYes οNo

Frequent Headaches οYes οNo

Genital Herpes οYes οNo

Glaucoma οYes οNo

Hay Fever οYes οNo

Heart Attack/Failure οYes οNo

Heart Murmur οYes οNo

Heart Pace maker οYes οNo

Heart Trouble/Disease οYes οNo

Hemophilia οYes οNo

Hepatitis A οYes οNo

Hepatitis B or C οYes οNo

Herpes οYes οNo

High Blood Pressure οYes οNo

Hives or Rash οYes οNo

Hypoglycemia οYes οNo

Irregular Heartbeat οYes οNo

Kidney Problems οYes οNo

Leukemia οYes οNo

Liver Disease οYes οNo

Low Blood Pressure οYes οNo

Mitral Valve Prolapse οYes οNo

Pain in Jaw Joints οYes οNo

Parathyroid Disease οYes οNo

Psychiatric Care οYes οNo

Radiation Treatments οYes οNo

Recent Weight Loss οYes οNo

Renal Dialysis οYes οNo

Rheumatic Fever οYes οNo

Rheumatism οYes οNo

Scarlet Fever οYes οNo

Shingles οYes οNo

Sickle Cell Disease οYes οNo

Sinus Trouble οYes οNo

Spina Bifida οYes οNo

Stomach/Intestinal Disease οYes οNo

Stroke οYes οNo

Swelling of the limbs οYes οNo

Thyroid Disease οYes οNo

Tonsillitis οYes οNo

Tuberculosis οYes οNo

Tumors or Growths οYes οNo

Ulcers οYes οNo

Venereal Disease οYes οNo

Yellow Jaundice οYes οNo

Have you ever had any serious illness not listed above? οYes οNo

If yes, Please explain______________________________________________________________________________________

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 patent’s) health. It is my responsibility to inform the dental office of any changes in medical status.

X________________________________________________________________________________________________

Signature of Patient/Guardian Date

Revised 05/2019

HIPPA/ FINANCIAL POLICIES for____________________________

Contact Information for Protected Health Information

I request that the following directives be adhered to for the disclosure of my Protected Health Information (PHI). This would include my name, diagnosis, x-rays, test results, date of services and financial information.

You may disclose information to my family and/or non-family members listed below:

Name:___________________________________ Relationship:__________________________ Phone #:_________________

Name:___________________________________ Relationship:__________________________ Phone #:_________________

ο You may leave Protected Health Information on my answering machine/voicemail using Phone #:___________________

ο You may send me a text message using Phone #:___________________

ο You may email me(unencrypted) for dental appointment’s. Email address: ____________________________________

I accept ο decline ο a copy of this office’s Notice of Privacy Practices.

X______________________________________________________________________________________________

Signature of Patient/Guardian Date

DENTAL INNOVATIONS OF COLUMBUS FINANCIAL POLICY

This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the most comprehensive dental care using only the highest quality material and technology available in the market today. We are also committed to providing you with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health. This Financial agreement is intended to facilitate our ability to provide excellent service to you while minimizing our costs to you.

Payment for Service is due at time services are rendered. Our practice accepts CASH, CHECKS, DEBIT OR CREDIT CARDS. No interest financing is also available through CARE CREDIT to qualified individuals. Returned checks and balances older than 60 days may be subject to collection fees and finance charges at a rate of 1.5% per month (18% annually).

Separated or divorced parents of minors who are responsible for half of the cost of a child’s dental care: The parent who brings the child into the dental appointment is responsible for paying the copayment or full fee. If it is necessary, we are happy to hold a Credit/Debit card number from the non-custodial parent on file.

As a courtesy to you, we will be happy to process all of your insurance claims. In order to do this, you must bring proof of your insurance with you to your appointment. All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is an agreement between you, your employer and the insurance company. Our practice is not a party to that agreement. If payment from your insurance company is not received within 60 days from the date of service, you will be expected to pay the balance in full. Your deductibles and any estimated co-payment for treatment is due at the time treatment is provided.

Additionally, our practice will charge $25 for appointments not kept and for appointments that are not rescheduled with at least 24 hours’ notice.

Please do not hesitate to ask if you have questions regarding this financial policy. We are committed to providing you with the best experience in dental care.

X________________________________________________________________________________________________

Signature of Patient/Guardian Date

Revised 05/2019

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