Poor 2. Is your present oral hygiene effective in cleaning your teeth? DNK 3. Have you ever had orthodontic braces?
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- Rosalyn Lucas
- 7 years ago
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1 B e l t l i n e R o a d, S u i t e 1 2 0, D a l l a s, T X P h o n e : F a x : A n s w e r e d 2 4 H o u r DATE: Last Name: Middle First Name: Birthdate: ˆ male ˆ female SS #: Marital status: ˆ married ˆ single ˆ divorced ˆ seperated ˆ widowed Occupation: Employer: Spouse s name: Home Address: City/State: Zip: Address: Home phone #: Work phone #: Other contact#: Previous/Current dentist: Name and Address of Physician: Referred by: Reason for making appointment: Name/Address and phone # of nearest living relative: DENTAL HISTORY: (circle, or, or if in doubt, circle for Do t Know) 1. How would you describe your dental health? Excellent Good Fair Poor 2. Is your present oral hygiene effective in cleaning your teeth? 3. Have you ever had orthodontic braces? 4. Are you satisfied with the way your teeth look? 5. Are your teeth sensitive to: hot cold sweetness pressure toothbrush 6. When were your teeth last cleaned? 7. If known, date of last set of complete dental x-rays? 8. Have you had an unfavorable experience in a dental office? 9. Have you had previous gum trouble? 10. Have you had a deep cleaning in the past? 11. If yes, what was treated and by whom? 12. Would the loss of a tooth (or teeth) disturb you? 13. What concerns you most about your mouth? 14. Do you use mints, hard candies etc. regularly? 15. Do you have a snoring problem? 16. Do you have dry mouth?
2 ISSUES ABOUT YOUR BITE AND/OR JAW JOINT 1. Are you aware of a tired feeling in your face? 2. Do you have ringing or pain in your ears? 3. Do you clench or grind your teeth? 4. Do you have frequent headaches? 5. Do you have pain around your ears, eyes, head, and/or neck? GENERAL HEALTH 1. Do you have any type of health problem? 2. Do you have high blood pressure? 3. Do you have low blood pressure? 4. Do you have shortness of breath after climbing a flight of stairs? 5. Do you bleed for more than 30 minutes for a minor cut? 6. Are you taking any medication? If so please list them & explain why you are taking them: 7. Have you been hospitalized in the last 5 years? If yes, please explain: 8. Do you faint easily or experience dizziness? 9. Have you taken cortisone/steroids in the last 6 months? 10. Have you been under the care of a physician in the last year for reasons other than a routine physical examination? 11. Have you had a major illness/serious operation in the last 5 years? If yes, please explain: 12. Have you had rheumatic fever? 13. Do you have any type of artificial joint/heart valve/pacemaker in place? If so, please explain: 14. Please circle an allergy to any of the following medications: Penicillin Keflex/ Keflin Xylocaine Phenaphen Tylenol Morphine Sulpha Erythromycin Vibromycin vocaine Codeine Valium Versed Tetracycline Carbocaine Aspirin Percodan Demerol Phenergan List any others: 15. Please estimate the number of glasses/cups you consume on an average day: Coffee Tea Soft Drinks Alcoholic Beverages 16 Do you smoke? If so, circle: Cigarette Cigar Pipe Betel Nut Chewing Tobacco How many in the average day: 17. Have you ever had an unusual reaction to Dental Anesthesia? 18. Do you have a latex allergy (gloves) or any metal allergies?
3 FAMILY HISTORY: (Please circle) 1. Have any family members (blood kin) had heart disease, high blood pressure, or diabetes? 2. Have any family members (blood kin) suffered complete tooth loss? MEDICAL HISTORY: (Do you now have, or have you ever had) 1. Do you need to pre-medicate before dental appointment? If yes, what do you take: 2. Blood Disorders (anemia, leukemia)? 3. Frequently swollen ankles? 4. Stomach ulcers? 5. Excessive thirst or hunger over an extended period of time? 6. Change in urination frequency? 7. Cuts which tend too heal slowly? 8. Diabetes Insulin or non Insulin Dependent? 9. Thyroid disturbance, or taken thyroid tablets? (Hypo or Hyper) 10. Do you have shortness of breath? 11. Hepatitis A, B or C? 12. AIDS or AIDS-related complex or positive for the AIDS virus? 13. Kidney or bladder disease/problems? 14. Stroke? 15. Arthritis or rheumatism? 16. Venereal disease (syphilis, ghonorrhea, herpes, HPV)? 17. Epilepsy, convulsions, or seizures? 18. Cancer or radiation therapy? 19. Any heart problems (mitral valve prolapse or a heart murmur)? 20. Nervous breakdown or psychotherapy? 21. Are you taking any sort of tranquilizers? 22. Are you taking any anticoagulants (blood thinners)? 23. Are you taking any antacids regularly? 24. Are you taking any mood elevators? If so, please list: 25. Glaucoma? 26. Asthma, hay fever, or eczema? 27. Do you use an inhaler? 28. Males only: Prostate problems? 29. Females only: Are you pregnant? Are you taking birth control pills/other hormones? 30. Have you ever taken Phen Phen or Redux? 31. Have you ever taken Fossomax? 32. Have you ever taken Bone Replacement Therapy? * Do you have any disease, condition, or problem not listed above that you think we should know about that you believe may affect treatment in any way? Patient or Guardian Signature:
4 Our Privacy Policy Guidelines: In our efforts to comply with the Health Information Privacy Act, HIPAA, we need to be certain that we guard your medical and dental information to the best of our ability. Please read, initial, and date the following so that you will be informed of how we will use your information. APPOINTMENT CONFIRMATION: By initialing the following, you are giving us permission to leave a message either at home or at work to confirm your appointments the day before they are scheduled. Preferred Number to call: REFERRING DOCTOR OR DOCTOR TO BE REFERRED TO: By initialing the following, you are allowing us to contact a referring doctor and discuss your treatment with their office or contact a doctor that we would like to refer you to and give them any information they may need in order to properly treat you. INSURANCE CLAIM PROCESSING: Dr. Rowan Buskin and Dr. Paulino Castellon do not accept insurance for payment of treatment. You, the patient, is responsible for payment of treatment at the time of service. We will however, fill out all necessary forms to send into your insurance provider to ensure prompt claim processing. By initialing the following, you are allowing us to send information to your insurance carrier for claim processing. DENTAL LAB WORK: By initialing the following, you are allowing us to transfer information to our dental technicians regarding treatment for you. PRIVACY POLICY: By initialing the following, you are accepting our privacy policy as written. I have read and understand each of the items listed above. Signature:
5 Radiograph Policy In Accordance With State Practice Guidelines In accordance to the guidelines of the Texas Occupations Code for Dentistry and by following the Standard of Care for our patients, Drs. Buskin and Castellon will complete a yearly exam on each patient as they are seen for their dental cleanings. At each exam, Drs. Buskin and Castellon evaluates the mouth for: 1) Tooth decay, fractures, or areas of enamel demineralization/weakening 2) Current integrity of existing restorations and need for replacement 3) Pathologies of the oral tissues and abnormal lesions 4) Existing bone, bone loss, and joint problems In order for our office to provide this Standard of Care and for Drs. Buskin and Castellon to complete a thorough, yearly exam, we will need to have radiographs of the oral cavity that will help ensure no potential issues are left undiagnosed. Drs. Buskin and Castellon will have only a limited understanding of the current condition of your mouth by directly viewing your teeth during an exam. In other words, early detection of any problem is best for your overall health and is made possible by utilization of radiographs. Please understand that the benefits of dental x-rays outweigh the potential hazards, for example, if there were a missed diagnosis of a jaw tumor that could be malignant or tooth decay that could develop into root canal and crown treatment, these problems could result in dental bills and pain that was avoidable. At our office, we share your concerns about x-radiation. This is why we follow strict standards when exposing radiographs, including: 1) Utilization of lead vests for your protection 2) Use of digital radiography, which reduces normal exposure by 1/2 to 1/3 3) Avoiding radiation to expectant mothers unless a dental emergency is present 4) Only taking check up x-rays on a yearly basis and taking panoramic or full mouth series of films every 3-5 years If Drs. Buskin and Castellon have prescribed their staff to take radiographs, then they believs that radiographs are a necessary prerequisite for your proper dental care. Signature:
6 Written Financial Policy Thank you for choosing Rowan Buskin, BDS. MSc. and Paulino Castellon DDS. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options. PAYMENT OPTIONS: You can choose from: Cash, Check, Visa, Mastercard, American Express or Discover Card We offer a 5% courtesy accounting adjustment to patients who pay for their treatment with cash or check prior to completion of care for treatment plans of $1000 or more. NO INTEREST 1 Payment Plans 2 from CareCredit Allow you to pay over time with NO INTEREST 1 Convenient, low monthly payment plans 2 also available annual fees or pre-payment penalties Please note: Rowan Buskin, BDS. MSc. and Paulino Castellon DDS. requires payment prior to the completion of your treatment. If you choose to discontinue care before treatment is complete, your refund will be determined upon review of your case. We accept payment in thirds. For plans requiring multiple appointments, alternative payment arrangements may be provided. We also offer in-house financing. For patients with dental insurance we are happy to work with your carrier to maximize your benefit and provide you with the documentation you need to receive reimbursement for your treatment. A fee of $40 per hour missed is charged for patients who miss or cancel more than 2 times in a calendar year without 24-hour notice. Rowan Buskin, BDS. MSc. charges Bank fees for returned checks. If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need. Patient, Parent or Guardian Signature Date Patient Name (Please Print) 1 If paid within the promotional period. Otherwise, interest assessed from purchase date. Minimum monthly payment required. 2 Subject to credit approval.
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