INSTRUCTIONS FOR FILLING OUT THE NEW PATIENT FORMS

Transcription

1 INSTRUCTIONS FOR FILLING OUT THE NEW PATIENT FORMS Please answer all questions on the welcome page. Please fill in all of your information on the ABOUT YOU page including where you live, the phone number there and your date of birth. Please enter all of the information for your POA or emergency contact. Please enter the name of your dental insurance company, your group number, your insurance ID number, the address of your dental insurance company and their phone number. All of this is on your dental insurance card. If your spouse is the dental insurance policy holder, please enter his/her name, date of birth and social security number. Please answer or check or circle all information on the Medical History page. It is a state requirement that we have this. Please do not say that the facility has it. We must have it in our records. The HIPAA Authorization Form must be signed. The Silver Nitrate Informed Consent must be signed. The Consent for Treatment must be initialed on each paragraph and signed at the end. If you would not mind it your photo or a video of our care for you is used on our web page, please sign the photo/video release. If you do not want us to use it, we will not. THANK YOU SO MUCH FOR CHOOSING DENTAL CARE IN YOUR HOME, INC. Please feel free to contact us at the information provided below if you should have questions, comment or concerns.

2 DENTAL TREATMENT CONSENT FORM FOR DENTAL CARE IN YOUR HOME, INC. PATIENTS Name of Dentist: Signature of Dentist: We make available this generalized dental consent form for your review and signature. Please do not hesitate to ask our dental staff any questions you may have. All dental procedures will be performed by licensed dentists and dental hygienists. Initial/introductory examinations will include a complete health history, x-rays, examination and charting of all existing conditions of the teeth and gums and a complete treatment plan before any operative or preventative care will be done. All procedures will be done in your own home or care facility. Please provide us with your dental insurance information, including the name of the person insured, address of the insurance company and their phone number. We also need your dental insurance ID number and complete social security number. 1. DRUGS AND MEDICATIONS (prescribed and administered by a licensed dentist) I understand that antibiotics, local anesthesia, analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). 2. CHANGES IN TREATMENT PLAN I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy or extraction following routine restorative procedures. 3. REMOVAL OF TEETH I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time (days or months) or fractured jaw. Postoperative instructions will be given to you or care provider verbally and written. 4. DENTURE AND PARTIALS

3 I realize that full or partial dentures may need to be adjusted if I have lost weight or lost additional teeth. I may need to have a new denture or partial made if my original one is lost, broken or cannot be adjusted. I realize the final opportunity to make changes in my new dentures or partial (including shape, fit, size, placement, color and materials used-resin only or a metal base and resin teeth) will be the teeth in wax try-in visit. I understand that most dentures require relining approximately three to twelve months after initial placement. Payment or insurance pre-authorization is due at time of service. Three adjustments will be included in the cost. Additional adjustments will be charged to you or your insurance. If you decide that you do not want the denture or partial after it is made, a refund of your payment cannot be made. 5. TEETH CLEANING AND RECALL APPOINTMENTS I understand that chronically inflamed gums put me more at risk for cardiovascular disease, type II diabetes, chronic obstructive pulmonary disease and the possibility of losing my teeth. I understand that I may need more than one cleaning every six months to gain and maintain healthy gums. 6. SILVER NITRATE/FLUORIDE VARNISH APPLICATION I understand that the application of silver nitrate followed immediately by the application of fluoride varnish may arrest decay and cause the treated area to become harder and pain free. This treatment is particularly important for gum line decay in the premolars and molars. It does cause the area treated to turn black. I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot guarantee results. I acknowledge that no guarantee or assurance has been made to me by anyone regarding the dental treatment that I have requested and authorized for myself or my minor child. I have had full opportunity to discuss and ask questions regarding the dental treatment, and all questions have been answered to my satisfaction. I HAVE READ, UNDERSTAND AND AGREE TO DENTAL AND DENTAL HYGIENE SERVICES THAT ARE NECESSARY FOR PROPER TREATMENT OF MY ORAL CONDITION. Patient s Name Date Signature of Patient Name of Parent, Guardian or Personal Representative Date Relationship to Patient

4 HIPAA Privacy Authorization Form Authorization for Use or Disclosure of Protected Health Information. (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164) 1. AUTHORIZATION: I authorize Dental Care In Your Home, Inc. to use and disclose the protected health information described below to my insurance company or specialist or my physician. 2. EFFECTIVE PERIOD: This authorization for release of information covers the period of health care beginning. 3. This medical information may be used by the person I authorize to receive this information for dental treatment or consultation, billing or claims payment, or other purposes as I may direct. 4. This authorization shall be in force and effect until I withdraw this authorization in writing, at which time this authorization expires. 5. I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim. 6. I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization. 7. I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law. Signature of patient or personal representative: Date: Printed name of patient or personal representative: His/her relationship to patient:

5 Welcome to Dental Care In Your Home, Inc. So that we can serve your dental needs according to your expectations, we would like to ask you a few questions. What is your main concern about your teeth and gums? How long has it been since your most recent dental care? What was done at that appointment? Are you apprehensive about dental care? Will you let another person help you with your dental care? How frequently would you like to have Dental Care in Your Home, Inc. clean your teeth? Whom may we thank for referring Dental Care In Your Home, Inc, to you? Thank you for filling out all of the new patient information sheets and signing or initialing where appropriate. We are honored to be asked to care for your needs.

6 ABOUT YOU Name: Date: Your address: City: State Zip: Your Phone Number: Date of Birth: EMERGENCY INFORMATION Person to contact: Relationship: Phone Number Address: City: State Zip: (if available): DENTAL INSURANCE INFORMATION {Please provide a copy (both sides) of your Insurance card} Name of Dental Insurance Company: Dental Insurance Company s Phone Number: Group#/Employer: ID/Social Security # Address of Insurance Company If spouse if your policy holder: Spouse s Name: Spouse s Date of Birth: Spouse s Social Security #:

7 MEDICAL HISORY Name of Personal Physician: Phone # Approx. Date of last Visit: Current Health: Excellent Good Fair Poor Have you had any serious health issues in the last five (5) years? Yes No if Yes, Please Explain: Are you taking: Blood Thinners? Yes No If yes, is INR < 3.5 Yes No Sleep Medication? Yes No Antidepressants? Yes No Anti-Anxiety Medication? Yes No Blood Pressure medication? Yes No Do you need to be Pre-Medicated with Antibiotics? Yes No, for Anxiety? Yes No Please list all prescriptions: Please Circle Anything You are Allergic to: Local Anesthesia Penicillin/Other Antibiotics Barbiturates Aspirin Sedatives Sleeping Pills Sulfa Drugs Shellfish Red Wine Codeine/Other Narcotics Iodine Latex Other Please circle any of the following you have had in the past: Alzheimer s Disease Anaphylaxis Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Breathing Problems Chest Pains Congenital Heart Disorder Convulsions Cortisone Medication Diabetes Emphysema Epilepsy or Seizures Excessive Bleeding Fainting Spells Glaucoma Heart Attack/Failure Heart Murmur Heart Pace Maker Heart Disease Hemophilia High Blood Pressure Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Pain In Jaw Joints Psychiatric Disorders Radiation Treatments Renal Dialysis Shingles Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tuberculosis Ulcers Any Serious illness not Listed Explain: I certify the above information is true & accurate to the best of my knowledge. Signature: Date:

8 Silver Nitrate Informed Consent Patient Name: Date: Silver Nitrate has been used in dentistry for over one hundred years. In recent years, it has been used in the Medical Management of Cavities with great success. Dental Care In Your Home, Inc. has been a leading innovator of this approach to care. The use of Silver Nitrate as an antimicrobial treatment of the infection that causes tooth cavities has been shown to be both effective and well received by thousands of patients over the past five years. With this in mind, Dental Care In Your Home, Inc. would like to obtain written consent for the following procedure. This consent may be revoked at any time. Dry Teeth - Application of 25% Silver Nitrate (FDA approved product) to appropriate teeth with visible cavities in very small amounts with a micro brush. One drop will treat 8 to 10 teeth. Then immediately apply a fluoride varnish (FDA approved product) over the treated cavity and the remainder of the teeth. The fluoride varnish helps to seal the Silver Nitrate into the cavity so it can destroy the bacteria causing the cavity. Fluoride varnish also assists to strengthen tooth enamel from future decay. This treatment may be repeated at 2, 4, 8 & 12 weeks following the initial application at the exam appointment. Following this protocol, the dentist will examine the patient and will suggest any necessary restorations. Contraindications: - Silver Nitrate Allergy (very rare) - Pregnancy. There is no evidence that Silver Nitrate as applied above might be harmful to the developing baby; however given the lack of information on this topic, we remain conservative. Possible Side Effects: - A cavity treated with Silver Nitrate will turn dark. This is a good indication that the infection in the tooth is dying. - If Silver Nitrate is placed on a tooth with a tooth colored restoration in it, some discoloration may occur. - Silver Nitrate placed on teeth with early demineralization (white spot) will cause discoloration. The side effects listed above may not include all of the possible situations reported by the drug s manufacturer. If you notice other effects please contact your dentist. This cavity arrest treatment does not eliminate the need for restorations in the future to repair function and esthetics. After the infection is eliminated, it often is not necessary to use local anesthetic (shots) when placing the filling. Do not eat or drink for one hour and do not brush your teeth for 24 hours after treatment. I hereby give permission for Dental Care In Your Home, Inc. to provide treatment with Silver Nitrate to the above named patient. I have read this form; I understand the treatment and have had the opportunity to ask questions. I also understand that I may refuse treatment with silver nitrate and select traditional care that may include placement of fillings prior to an antimicrobial step Patient Signature or Legal Guardian: Date: Doctor: Date:

9 PHOTO/VIDEO RELEASE FORM Date: Name: Address: City: State: Zip: Contact Phone Number: Alternate Phone Number: I, (Print Your Name) give permission for: Photographs to be taken for the purpose of documentation of comprehensive evaluation findings to be included in my dental records. Dental Care In Your Home, Inc. To use image(s) taken for any and all promotional purposes in electronic or printed media, including, but not limited to: brochures, websites, and other advertisements. I release Dental Care In Your Home, Inc. and/or the attending dentist, dental hygienist, and dental assistant from all responsibility. Signed: Date: Witnesses: Date: