Health History

PATIENT INFORMATION

Name: Birthdate: Social Security #:

Sex: Male Female

Address: City: State: ZIP:

Home Phone: Cell Phone: Work Phone: Ext:

Email: If student name of school: City: State:

Employer: Address:

Full Time: Full Time Part Time

Spouse/Parent/Guardian's Name: Number: Whom may we thank for referring you?

Person to contact in case of emergency: Phone: Relationship:

RESPONSIBLE PARTY

Name of Person Responsible for this Account: Relationship to Patient: Address: Home Phone: Birthdate: Employer:

Currently a patient in this office? Yes No

INSURANCE INFORMATION

PRIMARY INSURANCE

Name of Insured: Relationship to Patient: Birthdate: Social Security #: Date Employed: Employer: Phone Number: Insurance Company: Group #: Address: City: State: ZIP:

ADDITIONAL INSURANCE

Name of Insured: Relationship to Patient: Birthdate: Social Security #: Date Employed: Employer: Phone Number: Insurance Company: Group #: Address: City: State: ZIP:

Medical History Although dental personnel primarily treat the area around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you receive. Thank you for answering the following questions.

Reason for today's visit: Date of last dental exam: What was the exam for? Name of your last physician: Are you in good health? Date of last medical exam:

Are you under a physician's care?

Yes No

Have you ever been hospitalized or had a major operation?

Yes No

Have you ever had a serious head or neck injury?

Yes No

Are you taking any medications or supplements?

Yes No

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

Yes No

Have you ever taken Fosamax, Boniva, Actonel, or any other medications containing bisphosphonates?

Yes No

Do you use tobacco?

Yes No

Do you use controlled substances?

Yes No

Are you pregnant or trying to get pregnant?

Yes No

Are you nursing?

Yes No

Are you taking oral contraceptives?

Yes No

CHECKED ALL THAT APPLY:

FAMILY HISTORY UNKNOWN Yes No

Yes No

AIDS or HIV Positive

Alzheimer's Disease

Anaphylaxis

Anemia

Angina

Arthritis/Gout

Artificial Heart Valve

Artificial Joint

Asthma

Blood Disease

Blood Transfusion

Breathing Problem

Bruise Easily

Cancer

Chemotherapy

Chest Pain

Cold Sores/Fever Blisters

Congenital Heart Disorder

Convulsions

Cortisone Medicine

Diabetes

Drug Addiction

Easily Winded

Emphysema

Yes No

Epilepsy or Seizures

Excessive Bleeding

Excessive Thirst

Fainting Spells/Dizziness

Frequent Cough

Frequent Diarrhea

Frequent Headaches

Genital Herpes

Glaucoma

Hay Fever

Heart Attack/Failure

Heart Murmur

Heart Pacemaker

Heart Trouble/Disease

Hemophilia

Hepatitis A

Hepatitis B or C

Herpes

High Blood Pressure

High Cholesterol

Hives or Rash

Hypoglycemia

Irregular Heartbeat

Kidney Problems

Leukemia

Liver Disease

Yes No

Low Blood Pressure

Lung Disease

Mitral Valve Prolapse

Osteoporosis

Pain in Jaw Joints

Parathyroid Disease

Psychiatric Care

Radiation Treatments

Recent Weight Loss

Renal Dialysis

Rheumatic Fever

Rheumatism

Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Sleep Apnea

Smoking

Stomach/Intestinal Disease

Stroke

Swelling of Limbs

Thyroid Disease

Tonsillitis

Tuberculosis

Tumors or Growths

Ulcers

Venereal Disease

Have you ever had any serious illness not listed above? If yes, please explain:

Yes No

FAMILY HISTORY UNKNOWN:

Yes No

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:

Shady Spring Dental Care

Consent for Treatment/Financial Agreement

Consent for treatment:

The doctors and staff have explained to me the nature of the proposed dental treatment and expected benefits, risks, and alternatives. I authorize the doctor to make changes in treatment if, in the doctor's professional judgment, doing so is advisable. I understand that no guarantees have been made regarding treatment results and that I am responsible for following office and home-care instructions.

Patient Name: Date:

Patient/Guardian:

Date:

Financial Agreement:

I understand full payment is due for services rendered and that dental insurance is a contract between me and my insurance carrier. Any deductible, co-insurance, or estimated patient portion is my responsibility. If the account is placed with a collection agency or attorney, I agree to pay reasonable costs of collection, including attorney fees if allowed by law.

Confirmation/Cancellation Agreement

Due exclusively to the many costs of holding your appointment, we ask that if you need to cancel or reschedule you notify our office as soon as possible. Broken or short-notice appointments deprive another patient of needed treatment time and disrupt the schedule reserved specifically for you.

Appointments missed without 48 business hours notice may be charged. Repeated no-shows, short-notice cancellations, or repeated reschedules may result in prepayment requirements or limits on future scheduling.

A patient with an appointment missed or canceled less than 48 business hours before the visit or a no-show may be charged a broken-appointment fee.
After three broken appointments within the same twelve-month period, we may require prepayment before reserving future appointments.

Signature: Date:

Signature of Witness:

Date:

HIPAA Patient Consent Form

I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), 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; obtain payment from third-party payers; and conduct normal healthcare operations such as quality assessments and physician certifications.

I have reviewed your Notice of Privacy Practices containing a more complete description of uses and disclosures of my health information. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations.

Patient Name: Relationship to Patient:

Signature:

Date: