Welcome to Associates For Dental Care, LLC!

Transcription

1 Welcome to Associates For Dental Care, LLC! REGISTRATION FORM Section I Patient Information Name: I Prefer to be called: Address: City: State: Zip Phone ( ) Work Phone ( ) Cell Phone ( ) The best time to contact me is: A.M. P.M. on my Home phone Work phone Cell phone of Birth: Social Security Number: Check Appropriate Box: Minor Single Married Widowed Separated Divorced If Student, Name of School City/State FT PT Spouse or Parent s Name: Employer Work Phone Whom may we thank for referring you? Person to contact in case of emergency Phone Address Would you like to receive confirmations? Yes No Would you like to receive text confirmations? Yes No Section 2 Responsible Party Relationship to Patient: Self Spouse Parent Other Name: Relationship to Patient: Address: City: State: Zip: Phone: ( ) Employer Work Phone ( ) SSN# Section 3 Insurance Information Name of Insured DOB Relationship to Patient SSN#: Work Phone: ( ) Name of Employer: Address of Employer: City State: Zip Insurance Company Grp # ID# Ins Co Address: Ins Co. Phone: DO YOU HAVE ANY ADDIONAL INSURANCE? Yes No IF YES, COMPLETE THE FOLLOWING Name of Insured DOB Relationship to Patient SSN#: Name of Employer: Work Phone: ( )

2 Welcome to Associates For Dental Care, LLC! Address of Employer: City State: Zip Insurance Company Group # ID# Ins Co Address: Ins Co. Phone: Section 4 Medical History Physician s Name Phone Last Visit Your current physical health is: Good Fair Poor Are you taking any prescription/over the counter drugs? Yes No Please list: Have you ever had the following disease or medical problem: Yes No Abnormal Bleeding/ Hemophilia Yes No Tuberculosis (TB) Yes No Heart Surgery/ Pacemaker/ Heart Murmur Yes No Artificial Bones/Joints/Valves Yes No Anemia Yes No Artificial Bones/Joints/Valves Yes No Rheumatic fever causing heart defect Yes No Hepatitis A, B or C Yes No Asthma/ Emphysema/ Difficulty Breathing Yes No High/Low Blood Pressure Yes No Blood Transfusion Yes No HIV+/ AIDS Yes No Cancer/Chemo/Radiation Treatment Yes No Congenital Heart Defect Yes No Kidney/liver Problems Yes No Diabetes Yes No Arthritis/sterioid therapy Yes No Mitral Valve Prolapse Yes No Psychiatric Problems Yes No Scarlet Fever causing heart defect Yes No Drug/Alcohol Abuse Yes No Heart Attack/Stroke Yes No Glaucoma Yes No Severe/Frequent Headaches Yes No Epilepsy/Seizures/Fainting Spells Yes No Shingles/chicken pox Yes No Fever Blisters / Herpes Yes No Sinus Problems/hay fever Yes No Ulcers/colitis Yes No Venereal Disease Yes No Hospitalized for any reason Yes No Other Are you allergic to any of the following: Yes No Aspirin Yes No Dental Anesthetics Yes No Penicillin Yes No Metals/Plastics Yes No Erythromycin Yes No Tetracycline Yes No Codeine Yes No Latex Yes No Cotton Yes No Other FOR WOMEN: Are you taking birth control pills? Yes No Are you pregnant? Yes No No Are you nursing? Yes No I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent. Signature Patient or Guardian

3 Associates For Dental CARE, LLC ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES By signing this acknowledgement of Reciept of Notice of Privacy Practices {the Notice }; I acknowledge and agree that I have received a copy of the Notice of Privacy Practices for review and to keep for my records on the date identified below. I understand that Associates for Dental Care may use and disclose necessary personal health information (for example, my name, address, subscriber identification number, dental exam information and/or treatment provided) to another party to permit the party to perform it s administrative duties, provide me with dental care services and/or treatment, products, process my dental benefit claims and communicate with me regarding dental care services provided by Associates for Dental Care (for example, mailings of recall reminders or information about services, treatment and products privided by Associates for Dental Care. I can be assured that Associates for Dental Care does not sell my personal health information of any kind to a third party for such party s own use. I authorize the location to submit my dental benefit claims to my plan sponsor or health plan to receive reimbursement directly for the dental services and/or treatment that I have received from Associates for Dental Care. Patient Signature or Patient s Legal Representative Telephone: (773) Fax: (773) [email protected] Address: 4801 W. Peterson Ave., Ste# 550, Chicago, IL MEDICAL HISTORY I understand the above information and guarantee the information given is correct to the best of my knowledge and understand it is my responsibility to inform this office of any changes to the information I have provided. I understand that providing incorrect information can be dangerous to my (or patient s) health. Patient Signature or Patient s Legal Representative

4 Associates For Dental CARE, LLC Our Financial Policy Insurance Our office is committed to helping you maximize your insurance benefits. Because insurance policies vary, we can only estimate your coverage in good faith but cannot guarantee coverage due to complexities of insurance contracts. Your estimated patient portion must be paid at the time of service. As a service to our patients, we will bill insurance companies for services and allow them 45 days to render payment. After 60 days, you are responsible for the entire balance, paid-in-full. If you have any questions, our courteous staff is always available to answer them. Secondary Insurance As a courtesy we will bill your secondary carrier, but you are responsible for any balance after your primary insurance pays and secondary will be instructed to send you the check for their portion. Premium Lab Fee Our office uses a high quality lab for crowns and bridges. If your insurance downgrades our regular fees for crowns, there will be an additional premium lab fee charge. No Insurance For all services we expect the balance paid in full the day of service by cash, check or charge. Divorce Decrees This office is NOT a party to your divorce decree. All adult parties are responsible for their bill at the time of service and the adult accompanying their child to the visit is responsible for their child s bill. Minor Patients A parent or legal guardian must accompany all minor patients. The parent or legal guardian accompanying the minor is responsible for full payment of serviced for that visit. Appointments Your scheduled appointment time has been reserved specially for you. We request 24 hour notice if you need to cancel your appointment. We are aware that unforeseen events sometimes require missing appointment. After missing your second appointment without notifying us 24 hours in advance, you are subject to being charges an additional fee of $42/per hour. Returned checks All checks returned will be charged a $30.00 returned check fee for non sufficient funds. Collections In the event your account is turned over to an attorney or agency for collections, or suit is brought on, or the account is collected through any judicial proceeding whatsoever, the undersigned shall pay all reasonable costs of collection, including attorney fees, agency fees, court costs and finance charges incurred to our office to enforce payment. Thank you for understanding our Financial Policy. Please sign the Financial Policy with the understanding that you have read and understand it fully. Name of patient Name of responsible party if different Signature of responsible party

5 Associates For Dental CARE, llc Consent for Crowns, Bridges and Fillings Treatment 1. I understand that it is sometimes not possible to exactly match the color of natural teeth with artificial teeth. I realize that any changes I may desire in color, shape, size, etc. of restoration must be made prior to final fabrication and cementation. I further understand that I may be wearing temporary restorations that are prone to loosening and falling off and may need recementing. I will notify my doctor of that occurrence so that a temporary restoration is maintained until the final restoration is delivered. 2. It is my responsibility to schedule and return for final cementation of the restorations. I understand I may need further treatment in this office or possibly by a specialist if complications arise during treatment, and any costs thus incurred are my responsibility. I also understand that if my tooth does not respond to treatment with a crown, bridge or filling, further treatment such as root canal therapy may be necessary. 3. I understand that pain, bruising and occasional temporary or sometimes-permanent numbness in lips, cheeks, tongue or associated facial structure can occur with local anesthetics. About 99% of these cases resolve themselves in less than 8 weeks. Although very rarely needed, a referral to a specialist for evaluation and possibly treatment may be needed if the symptoms do not resolve. 4. It is the doctor s opinion that therapy will be helpful and worsening of the conditions would occur sooner without the recommended treatment. 5. Due to difficulty to reach certain teeth tissue trauma can occur from retracting cheeks, lips and tongue. 6. I understand that during the course of treatment it may be necessary to change or add procedures because of conditions discovered during treatment that were not evident during examination. I authorize my doctor to use professional judgment to provide appropriate care and understand that the fee proposed is subject to change, depending upon those unforeseen or undiagnosed conditions that may only become apparent once treatment has begun. CONSENT: My signature below signifies that I understand the treatment and anesthesia that is proposed for me, together with the known risks and complications associated with that treatment. I hereby give my consent for the treatment I have chosen. Patient s or Guardian s Signature

6 Associates For Dental CARE, llc Local Anesthesia Consent Form Although the use of local anesthetics to control pain is a safe, well-established procedure, adverse reactions can occur. These reactions include, but are not limited to, the following: 1. Fainting (vasopressor syncope) with or without a rapid pulse and lowered blood pressure. Usually associated with fear. 2. Rapid heartbeat (short term) can occur during the administration of local anesthesia. This is due to the epinephrine that is included in most anesthetics. Everybody has epinephrine in their body naturally, it is often referred to as adrenaline. However, it can make your heart feel like it is racing for a few minutes when the medication is first introduced into your body. If you already have high blood pressure, let the dentist know and an anesthetic can be used without epinephrine. 3. Hyperventilation syndrome is usually brought on by fear. It is characterized by tingling in the hands, lightheadedness and tightness in the chest. 4. Toxicity reactions initially appear as dizziness, blurred vision, or tremors and can proceed into drowsiness, convulsions, unconsciousness, or even respiratory or cardiac arrest. Toxicity reactions occur from an overdose or rapid absorption of the anesthetic into the bloodstream. Although we will never use more anesthetic than recommended for your body size, it is important to realize everybody has their own tolerance level. Pleases advise the doctor if you are more, or less, tolerant of medications in general. 5. Allergic reactions to today s local anesthetics (lidocaine/septocaine/carbocaine) are extremely rare. Allergic reactions are characterized by cutaneous lesions, edema/swelling, redness, and other manifestations of allergies. Anaphylactic reactions involving trouble breathing, rarely happen, but will require us to call 911 if they do occur to ensure your safety. 6. Idiosyncratic reactions of unexplained origin are exaggerated responses to an average dose of a drug. These reactions present clinically in a wide range of manifestations. Please inform the doctor if you have a history of severe reactions to medical treatment.

7 Associates For Dental CARE, llc 7. Numbness to additional areas of the face can occur due to variations in nerve anatomy. For example when we anesthetize the lower teeth the nerve branches carry anesthetic to the lower lip and tongue as well the teeth. Sometimes the anesthetic may be carried along other nerve branches as well, in turn numbing other areas of the face. Other common areas to receive anesthesia are the temples, eyelids, cheeks and chin. Often, when the eyelids are anesthetized, the effected eye cannot close and will tear up. These areas will start to feel and react normally once the anesthesia wears off. Anesthesia typically lasts between 1 and 4 hours but varies for each individual. 8. Paresthesia may occur if the nerve trunk is traumatized by the needle during the injection of anesthesia. This results in a residual tingling sensation, or in partial numbness of the affected tissue. Although paresthesia following a lower injection usually presents as a residual tingle in the lower lip and tongue, it can also affect the eyelids, cheeks and chin. The symptoms of paresthesia gradually diminish, and recovery is usually complete. It is important that you inform the dentist as soon as you experience symptoms of paresthesia so that you can undergo treatment right away if needed. Early treatment is essential for success in certain cases of paresthesia. 9. A quick feeling of shock can occur as the anesthetic is administered near the nerve. Often described as a feeling of electrical shock. This is normal and has no long term effects. Patient Doctor