New Patient Questionnaire

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Gervais Merritt
5 years ago
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New Patient Questionnaire 1.) What is the reason for your visit today? 2.) How were you referred to us? 3.) Have you had an unfavorable dental experience in the past? NO If yes, please explain: 4.

1 New Patient Questionnaire 1.) What is the reason for your visit today? 2.) How were you referred to us? 3.) Have you had an unfavorable dental experience in the past? NO If yes, please explain: 4.) Are you happy with your smile? NO If no, please explain: 5.) Would you like whiter teeth? YES NO 6.) Are you missing teeth? YES NO If yes, are you interested in replacing them? YES NO 7.) Are you especially anxious or nervous at the dentist? YES NO 8.) Do you clench or grind your teeth? YES NO 9.) Do you have jaw pain or discomfort? YES NO 10.) Do you have frequent headaches? YES NO 11.) Have you ever been told you have atmj problem or disorder? YES NO 12.) Do you snore or have you ever been diagnosed with sleep apnea? YES NO All of the preceding answers and information is true and correct to the best of my knowledge. Signature: :

2 MEDICAL HISTORY PATIENT NAME Birth Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician's care now? If yes, please explain: Have you ever been hospitalized or had a major operation? If yes, please explain: Have you ever had a serious head or neck injury? If yes, please explain: Are you taking any medications, pills, or drugs? If yes, please explain: Do you take, or have you taken, Phen-Fen or Redux? Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Are you on a special diet? Do you use tobacco? Do you use controlled substances? Women: Are you Pregnant/Trying to get pregnant? Taking oral contraceptives? Nursing? Are you allergic to any of the following? Aspirin Penicillin Codeine Local Anesthetics Acrylic Metal Latex Sulfa drugs Other If yes, please explain: Do you have, or have you had, any of the following? AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problem Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorde r Convulsions Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Radiation Treatments Recent Weight Loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice Have you ever had any serious illness not listed above? If yes, please explain: Comments: 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 medical status. SIGNATURE OF PATIENT, PARENT, or GUARDIAN DATE

3 Financial Agreement Responsible Party s Name: Last First MI Soc. Sec. # Relationship to Patient: Address: City: State: Zip: Home #: Work #: Cell #: Employer: Occupation: Address: City: State: Zip: Insurance Plan Name and Address: Insurance Plan Phone Number: Group Number: ID Number: As a condition of treatment at L. Patrick Grisanti II, DDS, PA, financial arrangements must be made in advance. Payment will be due at the time services are rendered unless other written financial arrangements have been made. Insurance claims will be filed as a courtesy, and your estimated portion will be due at the time services are rendered. I understand that insurance estimates cannot be guaranteed and are only estimates. It is the patient or responsible party s responsibility to understand his/her insurance policy including, but not limited to, exclusions, limitations, maximums, waiting periods, and covered/noncovered benefits. After all claims have been processed any unpaid portion must be paid in full by the patient or responsible party. Any credit will automatically be applied to the patient/responsible party s account unless a refund is requested. A service charge of 2% per month on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements have been made. I grant permission to you or your assignee to telephone me at home or at my work, and/or provide correspondence by mail to discuss matters related to my account or this form. I authorize assignment of benefits to L. Patrick Grisanti II, DDS, PA and this agreement will serve as my signature on file. The information on this form is accurate and I have read the above financial agreement and agree to their content. Signature of Patient/Responsible Party

4 Dental Treatment Consent Form 1.) Health Information: I agree to disclose all previous medical history, illness, conditions, and current/past medication. Undisclosed medical information can lead to potentially life threatening situations. 2.) Comprehensive Examination: As the standard of care for this practice, a new patient appointment will consist of the following: a current panoramic radiograph with four bitewing radiographs OR a full mouth series of x-rays; comprehensive examination; full mouth periodontal evaluation. In addition, other diagnostic tests may be necessary, including but not limited to, intra-oral and extra-oral photographs, pulp testing, additional radiographs, diagnostic casts. I authorize Dr. L. Patrick Grisanti II, DDS to perform any procedures or tests necessary to make a complete diagnosis of my dental needs. 3.) Additional or Specialty Care: I understand that I may need treatment beyond what was originally planned. Treatment plans may need to be modified at the time of treatment due to unexpected conditions or extent of disease progression. I agree to be financially responsible for the additional treatment or for referral toaspecialist. 4.) Gum treatment: I understand that this office requires a periodontal evaluation for all new patients. At this time the doctor will determine if a regular cleaning (prophylaxis) or deep cleaning (scaling and root planning) will be necessary. The cleaning appointment may need to be scheduled at a following appointment. Periodontal disease can have potential complications with overall systemic health, including diabetes, high blood pressure, preterm low birth weight babies, heart and cardiovascular disease, and other effects on systemic health. I understand that periodontal disease and disease progression is negatively affected by noncompliance with reevaluation and recall recommendations. 5.) Anesthesia: I understand that the use of local anesthetics has some potential risks including, but not limited to, temporary or permanent numbness, allergic reaction, cardiovascular and respiratory complications. I understand that these risks are present, accept all inherent risks and consent to the use of local anesthetics. 6.) Photographic/Radiographic Image Release: I authorize and give permission to L. Patrick Grisanti II, DDS to use my photographs, radiographs, and models for the following purposes: research, educational, and promotional purposes, including, but not limited to, use in publications, presentations, advertisements, internet and website content. 7.) Cancellation Policy: I agree to give 24 hour notice for cancellations or pay a potential broken appointment fee of $ I understand that leaving a message after office hours the day before is not sufficient notice. 8.) Requesting Record Transfers: If you would like copies of your records transferred to another healthcare provider, individual, or yourself, a signed written request must be given in advance. I understand that dentistry is not an exact science and I do not expect guarantees in dental care. I have had the opportunity to discuss the risks and benefits of dental treatment with Dr. L. Patrick Grisanti II, DDS and I have had all of my questions answered. I have read the above and accept all inherent risks and conditions associated with treatment by Dr. L. Patrick Grisanti II, DDS and staff. Signature of Patient/Parent or Guardian

5 CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION SECTION A: PATIENT/PARENT OR GUARDIAN GIVING CONSENT Name: Address: Telephone: Social Security #: SECTION B: TO THE PATIENT/PARENT OR GUARDIAN-PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry our treatment, payment activities, and healthcare operations. tice of Privacy Practices: You have the right to read our tice of Privacy Practices before you decide whether to sign this Consent. Our tice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our tice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our tice of Privacy Practices. I we change our privacy practices, we will issue a revised tice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our tice of Privacy Practices, including any revisions of our tice, at any time by contacting: Contact Person: L. Patrick Grisanti II, DDS Telephone: (972) Fax: (972) Address: 2504 Ridge Road, Suite 204, Rockwall, Texas Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of the Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent. CONSENT: I have had full opportunity to read and consider the contents of this Consent form and your tice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry our treatment, payment activities, and health care operations. If this Consent is signed by a personal representative on behalf of the patient, complete the following: Personal representative s Name: Relationship to Patient: Signature of Patient/Parent or Guardian You are entitled to a copy of this consent after signed.

Welcome and thank you for choosing Jerman Family Dentistry

Welcome and thank you for choosing Jerman Family Dentistry We provide dental services for the entire family. The following is helpful information to serve you better as a patient. If there are questions