INTRO First: How did you hear about us? DATE Last: Middle Initial: PATIENT INFORMATION: Preferred Name Gender Date of Birth / / Age Social Security # / / Home Phone Cell Phone Work Phone Email Occupation Emergency Contact Relationship Phone ACCOUNT INFORMATION: (If same as above, write same) Person Responsible for payment Relationship to patient Email address Home Phone Cell Phone Work Phone Occupation Social Security # / / DENTAL INSURANCE INFORMATION: Insurance Co. #1 Group Number Phone # Policyholder Date of Birth / / Social Security # / / Insurance Co. #2 Group Number Phone # Policyholder Date of Birth / / Social Security # / / I authorize release of any information necessary to effectively process my claim with my insurance carrier. I authorize payment directly to Orland Oaks Dental of the group insurance benefits otherwise payable to me. SIGNATURE SIGNATURE
Dental History Reason for today s visit: Date of Last Dental Cleaning: Date of Last Full Mouth X-rays: Date of Last Dental Visit: Concerns about today s visit: Have you ever been told to take a pre-medication prior to dental treatment? Concerns About Your Teeth Do you experience tooth sensitivity? SOMETIMES Do your gums bleed or hurt? SOMETIMES Are you a mouth breather? SOMETIMES Do you snore or have a sleep disorder? SOMETIMES Do you experience soreness, popping or clicking of your jaw? SOMETIMES Previous Dental Treatment Orthodontics? Oral surgery? Periodontal treatment? Bite plate or mouth guard? Serious injury to mouth or head? Tell Us About Your Smile Would you like your teeth to be whiter? Would you like to change anything about the appearance of your teeth? If so, what would you want to change? So we may provide you with exceptional quality of care, we would like to get to know you better and learn what is important to you. When you think about having dental treatment, which of the following would make you avoid having it completed? Please check all that apply: Fear Time Budget Experiencing Pain Lack of Trust in Dentists At Orland Oaks Dental, all of the following are important to us regarding your dental care. Which one is the most important value to you regarding your dental health? Please check one: Function (chewing your food) Comfort Cosmetic Keeping Your Teeth/Gums healthy for a Lifetime What is the most important quality you want to see in our doctors at Orland Oaks Dental?
Patient Acknowledgement and Consent of tice of Privacy Practices Our tice of Privacy Practices (NPP) provides information about how we may use and disclose protected information about you and how you can get access to this information, in compliance with the Health Insurance Portability and Accountability Act of 1996 / 2013 (HIPAAP). Please request a copy of our NPP if you want detailed information on your rights and our responsibilities in protecting your information. By signing this form, you consent to our use and disclosure of protected health information about you, including in electronic form. The patient understands that this information can and will be used to: Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly. Obtain payment from third party payers. Protected health information may be disclosed or used for treatment and billing for your services. This includes communication with your doctors and insurance carriers. We will not sell or use your information for marketing or fundraising. The Practice has NPP and that the patient has the opportunity to obtain a copy now and a revised copy if it is changed. The patient has the right to request changes to the Consent in writing at any time. contact you. Messages will be left at phone numbers provided. If you would like to give us permission to discuss your care with any other person please list them: I acknowledge that I have read the above excerpt and that I am able to receive a full copy of the tice of Privacy Practices upon my request. If applicable, I have also granted permission for Orland Oaks Dental, PC to share information regarding my dental care with the above listed individuals: Patient s Signature: Print Parent / Responsible Party Signature: Practice Witness:
WELCOME Thank You for choosing us! 10730 W. 165th Street, Orland Park, IL tel 708-460-3040 Medical History Patient 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? Have you ever been hospitalized or had a major operation? Have you ever had a serious head or neck injury? Are you taking any medication, pills or drugs? 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? For Women Are you: pregnant / trying to get pregnant? Are you allergic to any of the following? Aspirin Penicillin Codeine Other Taking oral contraceptives? Local Anesthetics Acrylic Metal Latex Nursing? Sulfa Drugs Do you have, or have you had, any of the following? AIDS/HIV Positive Alzheimer s Disease Anaphylaxis Anemia Angina Arthritis / Gout Asthma Blood Disease Blood Transfusion Breathing Problems Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenial Heart Disorder 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 Have you ever had any serious illness not listed above? 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 Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice Comments: To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information Signature of Patient, Parent or Guardian:
Consent for Treatment I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (name of patient) s dental needs. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that the use of anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications. I give consent to the doctors or designated staff s use and disclosure of any oral, written or electronic health records that are only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available. I consent to the use of photographs of my teeth/mouth for educational or marketing purposes. I understand that regardless of my insurance status, I am ultimately responsible for the total balance on my account for any professional services rendered. Furthermore, I understand that payment is due at the time of service unless other arrangements have been made. Should my account become delinquent, I agree to pay interest at a rate of 1 ½% per month (18% APR). If required, I also understand a credit check may be completed for certain arrangements (you will be fully informed). Patient s Signature: Parent / Responsible Party Signature: