SONORAN VALLEY DENTAL CENTER 3719 W. Anthem Way, Suite 101 Anthem, AZ (623)

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1 SONORAN VALLEY DENTAL CENTER (623) MEDICAL HISTORY PATIENT NAME: DATE: PATIENT ADDRESS: ZIP: PATIENT SS #: PATIENT DOB: CELL: ADDRESS HOW DID YOU HEAR ABOUT OUR OFFICE?: HOW DO YOU PREFER TO RECEIVE NOTIFICATIONS? (Appointment scheduling, confirmations, etc.) Text Phone Call Mail DENTAL HISTORY Name of Previous Dentist: Phone Number: What was the date of your last dental exam? Xrays? Cleaning? How often do you brush? Floss? Have you had or currently have braces? Yes No Do you have anxiety about having dental treatment? Yes No MEDICAL HISTORY Are you under a physician s care now? Why? Yes No If yes - Physicians Name: Phone Have you ever been hospitalized or had a major operation? If yes, please list reason below: Yes No Do you have TMJ problems? Discuss Yes No Have you ever had a serious injury to your head or neck? Discuss Yes No Are you on a special diet? Discuss Yes No Do you drink alcoholic beverages: If yes, how often? Yes No Do you use tobacco? (which one) Chewing tobacco Cigarettes Pipe E-Cigarette Yes No If yes, please indicate daily frequency and how long? Are you allergic to any medications or substances? Please check box below Yes No Aspirin Penicillin Codeine Acrylic Metal Latex Rubber Other Women (Please check): Pregnant/trying to get pregnant Nursing Taking oral contraceptives Please list any medications, pills or drugs that you are currently taking or give a list to the office to make a copy. To the best of my knowledge, all the preceding answers are correct. If I have any changes in my health status or if my medicines change. I shall inform the dentist and staff at the next appointment without fail. X Date PATIENT SIGNATURE (PARENT OR GUARDIAN) Reviewed By Doctor Date BP History Review and Significant Findings

2 Do you now have or have you ever had any of the following? Please check appropriate boxes. *If yes to any of the starred conditions, please call prior to your appointment premedication may be required. Yes No Yes No Heart Murmur* Frequent Diarrhea Mitral Valve Prolapse* Diabetes Artificial Heart Valve* Excessive Thirst Rheumatic Fever* Hypoglycemia Artificial Joint* Liver Disease Renal Dialysis* Hepatitis A (Infection) Kidney Problems* Hepatitis B or C Heart Attack/Failure Night Sweats Congenital Heart Disorder Yellow Jaundice Angina/Chest Pain Unexplained Fever Heart Pace Maker Blood Disease Heart Surgery Thyroid Disease High Blood Pressure Parathyroid Disease Low Blood Pressure Arthritis/Gout Heart Trouble/Disease Rheumatism Irregular Heart Beat Pain in Jaw Joints Bruise Easily Cortisone Medicine Anemia Scarlet Fever Excessive Bleeding Venereal Disease Sickle Cell Disease AIDS Hemophilia HIV Positive Leukemia Genital Herpes Recent Blood Transfusion Drug Addiction/Alcoholism Swelling on Limbs Tattoos Lung Disease Cold Sores Breathing Problem Fever Blisters Shortness of Breath Herpes Frequent Cough Stroke Hay Fever Convulsions Sinus Trouble Epilepsy or Seizures Asthma Fainting or Dizziness Bloody Sputum Glaucoma Emphysema Tumors or Growths Tuberculosis Nervousness Cancer Psychiatric Care X-Ray Treatments (Radiation) Alzheimer s Disease Chemotherapy Allergies (Medicines) Stomach/Intestinal Disease Allergies (Pollen/Dust) Ulcers Hives or Rash Recent Weight Loss Need Premedication? Have you ever had any other serious illness not checked above? If yes, please list below. Yes No Do you wish to talk to the dentist privately about any problem? Yes No

3 Sonoran Valley Dental Center (623) Welcome to Sonoran Valley Dental Center. We hope that this information form will answer some of your questions about our office s financial and insurance policies. Payment is expected at the time the service is performed. We accept cash, personal checks with proper identification, Visa, Mastercard, Discover, American Express or debit card. Insurance Filing The patient is ultimately responsible for payment in full of their account, NOT THE INSURANCE COMPANY. We do, however, file dental insurance claims as a courtesy to our patients. Most insurance companies have their own schedules of allowable charges for each procedure and they may not be the same as the actual charges in our office. Based on our experience with your insurance company, we will calculate your co-pay as closely as possible. Extended Payments We do not have in-house financing for extended payments. We do, however, have applications for payment plans from Care Credit. This financing program must be in place prior to your treatment appointment. Collection We realize that temporary financial problems may affect timely payment of your account. If such problems arise, we encourage you to contact us promptly for assistance. Any account turned over to a collection agency forfeits any past special fees and/or discounts. Such special fees and/or discounts will be reversed and you will be responsible for payment of the regular fee for procedures at the time of service. If an account cannot be cleared within 60 days, it will be reported as a bad debt with all three credit reporting agencies. We prefer not to use a collection service, but if circumstances make it necessary for us to pursue a collection account, all collection fees, attorney fees and interest at the rate of 1.5% per month may be added. Cancellation Fee A cancellation fee of $65.00 will be assessed to your account for a no-show or cancellation without 24 hours notice. I ACCEPT FULL FINANCIAL RESPONSIBILITY FOR THE SERVICES RENDERED TO ME BY THE STAFF AT SONORAN VALLEY DENTAL CENTER. I HAVE READ, UNDERSTAND AND AGREE TO THE POLICIES OUTLINED ABOVE. Signature Date

4 Acknowledgement Of Privacy Practices Sonoran Valley Dental Center My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to: Provide and coordinate my treatment among a number of health care providers who may be involved in the treatment directly and indirectly. Obtain payment from third-party payers for my health care services. Conduct normal health care operations such as quality assessment and improvement activities. I have been informed of my dental provider s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact his office at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations and I understand that you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. Patient Name: Signature: Date: Relationship to Patient: Dependent family members also covered by this acknowledgement: We were unable to obtain the patient s written acknowledgement of our Notice of Privacy Practices due to the following reason: The patient refused to sign Communication barriers Emergency situation Other

5 SONORAN VALLEY DENTAL CENTER (623) Social Media Consent/Release Form I hereby authorize Sonoran Valley Dental Center to use my photo and/or information related to my experiences with Dr. Gomez and/or Sonoran Valley Dental Center. I understand this information may by used in publications, including electronic publications, audiovisual presentations, promotional literature, advertising, community presentations, letters to area legislators and media and/or other similar ways. Sonoran Valley Dental Center will disclose to me or my legal representative, where appropriate, the specific information and/or photo to be used prior to release in the social media. My consent is freely given as a public service to Sonoran Valley Dental Center/Dr. Gomez, without expecting payment. I release Dr. Gomez and Sonoran Valley Dental Center and their respective employees, officers and agents from any and all liability which may arise from the use of such news media stories, promotional materials, written articles, videotape and/or photographs. I prefer that: My complete name be used My first name only be used No name be used I understand that I can revoke this release any time in writing and that the use of any of my photos or other information authorized by this release will immediately cease. Please print or type: Name: Address: City, State, Zip: Phone: Signature: Date: