Patient Information. Date: Home Phone: Work Phone: Cell: Address: City: State: Zip: Whom may we thank for referring you:

Transcription

1 DANIEL LEE, D.D.S. Prev entive Res torative Cosmetic Dentistry Patient Information Date: Home Phone: Work Phone: Cell: Name: Social Security Number: Address: City: State: Zip: Sex: M F Birthdate: Minor Single Married Widowed Divorced Patient Employed By: Business Address: Whom may we thank for referring you: In case of emergency who should be notified: Phone: Responsible Party Name of person responsible for the account: Phone: Address of responsible party: City: State: Zip: Relationship to the patient: Birthdate: SSN: Dental Insurance Information Name of the Insured: Relationship to Patient: Insured s Date of Birth: SSN: - - Employer: Insurance Company: Phone: Group Number: Employee/Cert. Number: Insurance Company Address: City: State: Zip: Deductible: Amount Already Used: Maximum Annual Benefit: Do you have Secondary Insurance Coverage: Yes No If yes, please complete the following information: Name of Insured: Relationship to Patient: Insured s Date of Birth: SSN: - - Employer: Insurance Company: Phone: Group Number: Employee/Cert. Number: Insurance Company Address: City: State: Zip: Deductible: Amount Already Used: Maximum Annual Benefit: I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents. Signature of Patient or Parent if Minor: Date:

2 Reason for today s visit: Dental History When was your last dental visit: How often do you brush your teeth: What texture toothbrush do you use: Soft Medium Hard Is there anything about your smile that you do not like: What would you like to accomplish in your dental treatment: *Please circle an answer for each question listed below: Do you have any old fillings or treatment that you are unhappy with: Would you like your teeth to be whiter: Do your gums bleed while brushing: Do you have frequent headaches: Do your gums bleed when flossing: Do you clench or grind your teeth: Are your teeth sensitive to hot, cold, sweet or sour foods or liquids: Have you noticed any loosening of your teeth: Does food tend to become caught between your teeth: Do you have any sores or lumps in or near your mouth: Have you ever experienced any of the following problems in your jaw: Clicking Pain (joint, ear, side of face) Difficulty opening/closing Do you bite your lips or cheeks frequently: Have you ever had: Orthodontic treatment (Braces): Oral Surgery: Your teeth reshaped or bite adjusted: Worn a night guard, bite plate or other appliance: Are you satisfied with the appearance of your teeth and smile: Have you ever had an upsetting experience in a dental office: Is there anything about having dental treatment done that concerns you: Medical History Do you consider yourself to be in good health: Have you had any abnormal bleeding: Have there been any changes in your general health within the past year: When was your last physical exam: Physician s name: Address: Telephone: Are you currently under the care of a physician: Have you ever been hospitalized for any surgical operation or serious illness: If yes, please explain: Are you currently taking any medication(s) including nonprescription medicine(s): Have you had recent weight loss: Are you currently taking diet pills or herbs: Have you or are you currently taking osteoporosis medication such as Fosamax : Do you bruise easily: Have you ever required a blood transfusion: Do you use tobacco: Do you use alcohol: Do you use cocaine or other drugs: Are you wearing contact lenses: Do you have any disease, condition, or problem not listed above that you believe I should know about: If yes, please explain: Are you allergic to or have you had reactions to: Local anesthetics: Penicillin: Sulfa Drugs: Barbiturates, Sedatives or Sleeping Pills: Aspirin: Iodine: Latex: Other Antibiotics: Other Allergies:

3 Medical History Continued... Do you have, or have you ever had, any of the following: Rheumatic heart disease or rheumatic fever Scarlet Fever Heart defect Heart murmur Heart trouble Heart attack Angina Do you have pain in your chest upon exertion Are you ever short of breath after mild exercise Do your ankles swell Do you get short of breath when you lie down Do you require extra pillows when you sleep Pacemaker Heart Surgery High Blood Pressure Low Blood Pressure Hepatitis A B C Jaundice Liver Disease Stroke Lung or Breathing Problems Asthma Hay Fever Hives or Skin Rash Fainting Spells or Seizures Diabetes AIDS or HIV Infection Sinus Trouble Thyroid Problems Allergies Arthritis Rheumatism Joint Replacement Implant Stomach Ulcer Kidney Trouble Tuberculosis Persistent Cough Cough that produces blood Cancer Sexually Transmitted Disease Epilepsy Anemia Leukemia Eating Disorder Women Only: Are you pregnant or think you may be Are you nursing Are you taking birth control pills 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 my medical status. Signature of Patient, Parent or Guardian FOR COMPLETION For Completion BY DR. By Dr. OH Lee & STAFF Date Summary of Dental History: Summary of Medical History: Medical History Update: Initials: Date Comments Patient Dentist Hygienist

4 Financial Agreement Dr. Lee Oh and staff are committed to to providing you with the best possible dental care. If If you have dental insurance, we are anxious to help maximize your allowable benefits. In order to achieve these goals, we need your assistance and your understanding of our policy. PAYMENT: Fees are established according to services performed and payment is due at the time of service unless prior arrangements have been made. (If you have dental insurance, we require that you pay your estimated portion and deductible at the time of service.) A finance charge of 1% per month 12% per annum is assessed on any balance after 60 days. INSURANCE PAYMENT: To prevent misunderstandings, we inform our patients that insurance policies vary and that it is each patient s responsibility to pay for the services rendered, regardless of individual coverage. (We accept cash, personal check, Visa, MasterCard, Debit, Auto Pay and outside patient financing through CareCredit). We are happy to process your insurance claim for you if all necessary filing information has been provided to us (ie. correct insurance information, correct social security numbers, group number(s), signed benefit claim form, etc.). You must realize, however, that: 1. Your insurance is a contract between you, your employer and the insurance company. We are not a party to that company. 2. Not all services are a covered benefit in all contracts. Some insurance companies arbitrarily select certain services they will not cover. Thank you for your understanding. Please do not hesitate to let us know if you have any questions or concerns. I UNDERSTAND AND AGREE TO THE TERMS OF THIS FINANCIAL POLICY. Print Name: Date: Signature: Date:

5 "#$%&'()*(+($,-%.-/("(01,-%.-2,3,(+($,-% "7-453",0"(8- "#$%&'()*(+($,-%.-/("(01,-%.-2,3,(+($,-% "7-453",0"(8- I " acknowledge #$%&'()*+,* that -.#- I have ".#/* received 0*$*1/*+ a copy # $'23 of the '4 Statement -.* 5-#-*6*&- of Privacy '4 701/#$3 Practices 70#$-1$*8 for the 4'0 offices -.* of '441$*8 Glenwood '4 9'/1&,-'& Dental. The 561)*8: Statement ;.* of Privacy 5-#-*6*&-'4701/#$370#$-1$*8+*8$01<*8-.*-32*8'4=8*8#&++18$)'8=0*8'46320'-*$-*+.*#)-.1&4'06#-1'&-.#-61,.-'$$=0 Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment 1& 63-0*#-6*&-> for services, 2#36*&- or in the 4'0 performance 8*0/1$*8> '0 of 1& office -.* 2*04'06#&$* health care operations. '4 '441$*.*#)-. The Statement $#0* '2*0#-1'&8:;.* of Privacy Practices 5-#-*6*&- also describes '4 701/#$3 my " rights 70#$-1$*8 #$%&'()*+,* and #)8' the responsibilities -.#- +*8$01<*8 ".#/* 63 0*$*1/*+ 01,.-8 and duties #&+ # $'23 -.* of this '4 0*82'&81<1)1-1*8 -.* office 5-#-*6*&- with respect #&+ '4 701/#$3 +=-1*8 to my protected 70#$-1$*8 ' '441$* health 4'0 -.* (1-. information. '441$*8 0*82*$- '4 9'/1&,-'& -' The 63 Statement 20'-*$-*+ 561)*8: of.*#)-. Privacy ;.* 5-#-*6*&-'4701/#$370#$-1$*8+*8$01<*8-.*-32*8'4=8*8#&++18$)'8=0*8'46320'-*$-*+.*#)-.1&4'06#-1'&-.#-61,.-'$$=0 Practices 1&4'06#-1'&:;.*5-#-*6*&-'4701/#$370#$-1$*818#)8'2'8-*+1&-.*4#$1)1-3: is also posted in the facility. 1& 63-0*#-6*&-> 2#36*&- 4'0 8*0/1$*8> '0 1& -.* 2*04'06#&$* '4 '441$*.*#)-. $#0* '2*0#-1'&8:;.* 5-#-*6*&- '4 701/#$3 70#$-1$*8 Glenwood 9'/1&,-'&561)*80*8*0/*8-.*01,.--'$.#&,*-.*201/#$320#$-1$*8-.#-#0*+*8$01<*+1&-.*5-#-*6*&-'4701/#$370#$-1$*8:"4 #)8' Dental +*8$01<*8 reserves 63 the 01,.-8 right #&+ to change -.* 0*82'&81<1)1-1*8 the privacy practices #&+ +=-1*8 that '4 are -.18 described '441$* (1-. in the 0*82*$- Statement -' 63 of 20'-*$-*+ Privacy Practices..*#)-. If 1&4'06#-1'&:;.*5-#-*6*&-'4701/#$370#$-1$*818#)8'2'8-*+1&-.*4#$1)1-3: privacy 201/#$320#$-1$*8$.#&,*>"(1))<*'44*0*+#$'23'4-.*0*/18*+5-#-*6*&-'4701/#$370#$-1$*8#--.*-16*' /181-#4-*0 practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions -.*0*/181'&8<*$'6**44*$-1/*:"6#3#)8''<-#1&#0*/18*+5-#-*6*&-'4701/#$370#$-1$*8<30*?=*8-1&,-.#-'&*<*6#1)*+-' become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me. 9'/1&,-'&561)*80*8*0/*8-.*01,.--'$.#&,*-.*201/#$320#$-1$*8-.#-#0*+*8$01<*+1&-.*5-#-*6*&-'4701/#$370#$-1$*8:"4 6*: 201/#$320#$-1$*8$.#&,*>"(1))<*'44*0*+#$'23'4-.*0*/18*+5-#-*6*&-'4701/#$370#$-1$*8#--.*-16*' /181-#4-*0 -.*0*/181'&8<*$'6**44*$-1/*:"6#3#)8''<-#1&#0*/18*+5-#-*6*&-'4701/#$370#$-1$*8<30*?=*8-1&,-.#-'&*<*6#1)*+-' "##$%$&'"(#$)*(&)+,-"+%.&,$%/ 6*: $ :8723;<85;=>7;27;<>3: )4147?7045@A>3B1<CA>1<43<7;D$67>7:C;E7<3@3<188C "##$%$&'"(#$)*(&)+,-"+%.&,$%/ 1=465>3F723;<85;=>75@?CA>547< <1>730@5>? E7>;50;3023<1472:7859G $ :8723;<85;=>7;27;<>3: )4147?7045@A>3B1<CA>1<43<7;D$67>7:C;E7<3@3<188C "'/H-HI-,&JH/$HH-#$"%-J"H$(/ /-) '& 1=465>3F723;<85;=>75@?CA>547< <1>730@5>? E7>;50;3023<1472:7859G )A&+)-&'(/ /-) '& &%.-,@PLEASE SPECIFYAB /-) '& "'/H-HI-,&JH/$HH-#$"%-J"H$(/ /-) '& )A&+)-&'(/ /-) '& CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC &%.-,@PLEASE SPECIFYAB /-) '& '1?75@A143704'07*08'&#)D*20*8*&-#-1/* )3K014=>75@A143704'07*08'&#)D*20*8*&-#-1/* CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC CCCCCCCCCCCCCCCCCCCCCCCCCCC CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC '1?75@A143704'07*08'&#)D*20*8*&-#-1/* E#-* )3K014=>75@A143704'07*08'&#)D*20*8*&-#-1/* E*8$012-1'&'47*08'&#)D*20*8*&-#-1/*F8G=-.'01-3 CCCCCCCCCCCCCCCCCCCCCCCCCCC CCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCCC E#-* &JJ$*-+)-&'(/I-(&L%.$)($'- E*8$012-1'&'47*08'&#)D*20*8*&-#-1/*F8G=-.'01-3 Record &JJ$*-+)-&'(/I-(&L%.$)($'- of Acknowledgement Not obtained /-) A,&M$#-#A,$&,%&%,-"%H-'%N Record of Acknowledgement #"%-)%"%-H-'%A,&M$#-#OPPPPPPPPPPPPPPPPPP '& Not obtained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th St. SW, 9'/1&,-'&>NGOPQLK Suite #202 Lynnwood, WA 98012