Lake City Cosmetic Dentistry 3340 NE 125 th Street Seattle, WA
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1 Lake City Cosmetic Dentistry 3340 NE 125 th Street Seattle, WA ACKNOWLEDGMENT OF RECEIPT OF STATEMENT OF PRIVACY PRACTICE I acknowledge that I have received a copy of the Statement of Privacy Practices for the office of Lake City Cosmetic Dentistry. The Statement of Privacy Practices describes the types of uses and disclosures of my [protected health information that might occur in my treatment, payment of service, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility. Lake City Cosmetic Dentistry reserves the right to change the privacy practices that are described in the Statement of Privacy practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices by requesting that one be mailed to me. ADDITIONAL DISCLOSURE AUTHORITY In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below: ANY MEMBER OF MY IMMEDIATE: YES NO SPOUSE ONLY: YES NO OTHER (please specify): YES NO Name of Patient or Personal Representative Signature of Patient or Personal Representative Date Description of Personal Rep. s Authority OFFICIAL USE ONLY BELOW THIS LINE RECORD OF ACKNOWLEDGMENT NOT OBTAINED PROVIDED PRIOR TO TREATMENT? YES NO DATE PROVIDED: REASON FOR DENIAL Needed more time to review Statement of Privacy Practices Wanted to consult with another person before signing Unable to sign Reason not given Other (explain):
2 LAKE CITY COSMETIC DENTISTRY Dr. Ryan Chiang & Dr. Garret Yamaguchi 3340 NE 125 th Strett Seattle, WA Financial Policy INSURED PATIENTS Patients with insurance are asked to pay the deductible and estimated patient portion at the time of treatment. We are more than happy to file your insurance claim for you. Please keep in mind that the estimated portion is just that, an estimate. Filling insurance claims is a courtesy that we extend to our patients. We make every effort to follow up on unpaid insurance claims, however if we have not received payment after 60 days we ask you to discuss your claim with your insurance company. NON-INSURED PATIENTS If you do not have dental insurance, we ask for payment in full at the time of service. If you feel that financial arrangements are necessary, you may discuss this with the front office staff before treatment is started. USUAL AND CUSTOMARY RATE (UCR) Our practice is committed to providing the best treatment possible for our patients. Our fees reflect the usual and customary rates for our area. Keep in mind that the rates paid by your insurance carrier are determined by the insurance carrier and your employer and, in some situations, have no bearing on the real usual and customary rates charged in the local area. NO-SHOW AND CANCELLATION POLICY Your visit has been reserved for you. If you are unable to keep your appointment we require 48 hours notice for cancellation/re-scheduling. If 48 hours notice is not provided a late cancellation fee of $ will be applied to your account. DIVORCES Both partners are responsible for the debts incurred up to the date of the divorce decree. The parent who requests treatment for a child is responsible for the balance of services rendered for your child. LATE AND FINANCE CHARGES A finance charge will be imposed on those charges not paid in full within 90 days of the day treatment was rendered. The finance charge is periodic rate of 1.0% per month (12% annually). The amount of the late charge will be as authorized under the laws of Washington, with a minimum charge of $1.00 EMERGENCIES Should you experience a dental emergency during non-business hours, please call our office. The recorded phone message will provide an emergency contact number. STATEMENT OF UNDERSTANDING Patient Signature: Date: Signature: Date:
3 MEDICAL HISTORY Patient Name Nickname Age Name of Physician/and their specialty Most recent physical examination Purpose What is your estimate of your general health? Excellent Good Fair Poor DO YOU HAVE or HAVE YOU EVER HAD: YES NO 1. hospitalization for illness or injury 2. an allergic reaction to aspirin, ibuprofen, acetaminophen, codeine penicillin erythromycin tetracycline sulpha local anesthetic fluoride metals (nickel, gold, silver, ) latex other 3. heart problems, or cardiac stent within the last six months 4. history of infective endocarditis 5. artificial heart valve, repaired heart defect (PFO) 6. pacemaker or implantable defibrillator 7. artificial prosthesis (heart valve or joints) 8. rheumatic or scarlet fever 9. high or low blood pressure 10. a stroke (taking blood thinners) 11. anemia or other blood disorder 12. prolonged bleeding due to a slight cut (INR > 3.5) 13. emphysema, sarcoidosis 14. tuberculosis 15. asthma 16. breathing or sleep problems (i.e. snoring, sinus) 17. kidney disease 18. liver disease 19. jaundice 20. thyroid, parathyroid disease, or calcium deficiency 21. hormone deficiency 22. high cholesterol or taking statin drugs 23. diabetes (HbA1c = ) 24. stomach or duodenal ulcer 25. digestive disorders (i.e. gastric reflux) 26. osteoporosis/osteopenia (i.e. taking bisphosphonates) 27. arthritis 28. glaucoma 29. contact lenses 30. head or neck injuries 31. epilepsy, convulsions (seizures) 32. neurologic problems (attention deficit disorder) 33. viral infections and cold sores 34. any lumps or swelling in the mouth 35. hives, skin rash, hay fever 36. venereal disease 37. hepatitis (type ) 38. HIV / AIDS 39. tumor, abnormal growth 40. radiation therapy 41. chemotherapy 42. emotional problems 43. psychiatric treatment 44. antidepressant medication 45. alcohol / drug dependency ARE YOU: 46. presently being treated for any other illness 47. aware of a change in your general health 48. taking medication for weight management (i.e. fen-phen)_ 49. taking dietary supplements 50. often exhausted or fatigued 51. subject to frequent headaches 52. a smoker or smoked previously 53. considered a touchy person 54. often unhappy or depressed 55. FEMALE - taking birth control pills 56. FEMALE - pregnant 57. MALE - prostate disorders YES NO Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment. List all medications, supplements, and or vitamins taken within the last two years Drug Purpose Drug Purpose Ask for an additional sheet if you are taking more than 6 medications PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING. Patient s Signature Date Doctor s Signature Date v Kois Center, LLC To reorder, please visit:
4 Referred by How would you rate the condition of your mouth? Excellent Good Fair Poor Previous Dentist How long have you been a patient? Months/Years Date of most recent dental exam / / Date of most recent x-rays / / Date of most recent treatment (other than a cleaning) / / I routinely see my dentist every: 3 mo. 4 mo. 6 mo. 12 mo. Not routinely WHAT IS YOUR IMMEDIATE CONCERN? PLEASE ANSWER YES OR NO TO THE FOLLOWING: YES NO PERSONAL HISTORY 1. Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most) [ ] 2. Have you had an unfavorable dental experience? 3. Have you ever had complications from past dental treatment? 4. Have you ever had trouble getting numb or had any reactions to local anesthetic? 5. Did you ever have braces, orthodontic treatment or had your bite adjusted? 6. Have you had any teeth removed? SMILE CHARACTERISTICS 7. Is there anything about the appearance of your teeth that you would like to change? 8. Have you ever whitened (bleached) your teeth? 9. Have you felt uncomfortable or self conscious about the appearance of your teeth? 10 Have you been disappointed with the appearance of previous dental work? BITE AND JAW JOINT 11. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) 12. Do you / would you have any problems chewing gum? 13. Do you / would you have any problems chewing bagels, baguettes, protein bars, or other hard foods? 14. Have your teeth changed in the last 5 years, become shorter, thinner or worn? 15. Are your teeth crowding or developing spaces? 16. Do you have more than one bite and squeeze to make your teeth fit together? 17. Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? 18. Do you clench your teeth in the daytime or make them sore? 19. Do you have any problems with sleep or wake up with an awareness of your teeth? 20. Do you wear or have you ever worn a bite appliance? TOOTH STRUCTURE 21. Have you had any cavities within the past 3 years? 22. Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? 23. Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? 24. Are any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth? 25. Do you have grooves or notches on your teeth near the gum line? 26. Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? 27. Do you get food caught between any teeth? GUM AND BONE DENTAL HISTORY 28. Do your gums bleed when brushing or flossing? 29. Have you ever been treated for gum disease or been told you have lost bone around your teeth? 30. Have you ever noticed an unpleasant taste or odor in your mouth? 31. Is there anyone with a history of periodontal disease in your family? 32. Have you ever experienced gum recession? 33. Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? 34. Have you experienced a burning sensation in your mouth? Patient s Signature Date Doctor s Signature Date To reorder, please visit: Kois Center, LLC - v2.1
5 P L E A S E CONFIDENTIAL INFORMATION QUESTIONNAIRE PATIENT S LEGAL NAME LAST, FIRST MI DATE OF BIRTH SEX SOCIAL SECURITY # P R I N T PREFER TO BE CALLED HOME PHONE # CELL PHONE # PATIENT S ADDRESS STREET APT# CITY STATE ZIP MARITAL STATUS S M W D UNDER AGE 18 PATIENT S / GUARDIAN S EMPLOYER WORK ADDRESS STREET APT# CITY STATE ZIP OCCUPATION WORK PHONE # SPOUSE S NAME LAST, FIRST MI SPOUSE S EMPLOYER OCCUPATION SPOUSE S WORK ADDRESS STREET APT# CITY STATE ZIP WORK PHONE # OTHER FAMILY MEMBERS THAT ARE PATIENTS HERE WHO CAN WE THANK FOR REFERRING YOU TO OUR OFFICE? EMERGENCY CONTACT INFORMATION PERSON WE MAY CONTACT IN CASE OF AN EMERGENCY (OTHER THAN YOUR FAMILY HOME) NAME RELATIONSHIP HOME PHONE # WORK PHONE # CELL PHONE # REQUEST FOR CONFIDENTIAL COMMUNICATION AS MY DENTAL CARE PROVIDER, YOU MAY DO THE FOLLOWING WITH MY PERMISSION: Contact me at home Contact me via cell phone Contact me at work Contact me via Leave messages on my home voic / answering machine Leave messages on my cell phone voic Leave messages on my work voic / answering machine v Kois Center, LLC To reorder, please visit: YES NO
6 INSURANCE COVERAGE YES P L E A S E P R I N T INSURANCE AND FINANCIAL INFORMATION NO SUBSCRIBER S NAME INSURANCE COMPANY NAME INSURANCE ADDRESS PATIENT S RELATIONSHIP TO SUBSCRIBER SUBSCRIBER S BIRTHDAY INSURANCE PHONE SUBSCRIBER S SSN / ID # SELF SPOUSE DEPENDENT GROUP / PROGRAM NUMBER EMPLOYER (IF DIFFERENT FROM ABOVE) EMPLOYER S ADDRESS SECONDARY COVERAGE INSURANCE COMPANY NAME INSURANCE ADDRESS INSURANCE PHONE YES NO SUBSCRIBER S NAME PATIENT S RELATIONSHIP TO SUBSCRIBER SUBSCRIBER S BIRTHDAY SUBSCRIBER S SSN / ID # SELF SPOUSE DEPENDENT GROUP / PROGRAM NUMBER EMPLOYER (IF DIFFERENT FROM ABOVE) EMPLOYER S ADDRESS Health Care Providers Insurance Companies RELEASE INFORMATION YOU MAY DISCUSS MY HEALTHCARE WITH YES NO OTHERS (PLEASE PRINT) ( CONFIRMATIONS DO YOU PREFER A CONFIRMATION CALL No, it is unnecessary Yes, it is a helpful reminder ASSIGNMENT & RELEASE I hereby authorize my insurance benefits to be paid directly to the dentists. I am financially responsible for any balances due and authorize the dentists to release any information for this claim. I authorize that my records can be used by the doctor if he so determines. In consideration of the services rendered to me by this dental office, I am obligated to pay said office in accordance with its credit terms and policy. I consent to making of videotapes, photographs, and x-rays before, during, and after treatment, and to use the same by the doctor in scientific papers or demonstrations. I certify that I have read or had read to me the contents of this form and do realize the risks and limitations involved. SIGNATURE - PATIENT / GUARDIAN DATE WITNESS SIGNATURE DATE v Kois Center, LLC To reorder, please visit:
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