DSNForms

Northeast Florida Periodontics & Dental Implants - Patient Form

Patient information

*Prefix

*First Name

Middle Name

*Last Name

*Date of birth

Social Security Number

Email

*Gender

Street Address 1

Street Address 2

Apt.

City

State

Zip

Primary Phone

Alternate Phone (Mobile, work, or home)

Have you ever been a patient of our practice?

Has a family member ever been a patient of our practice?

Dentist Name

First Name

Last Name

Orthodontist Name

First Name

Last Name

Medical Doctor Name

First Name

Last Name

Who were you referred by?

First Name

Last Name

Preferred Pharmacy Name

Preferred Pharmacy Phone

Upload your Driver's license

Maximum allowed size : 25MB

Upload your insurance card

Maximum allowed size : 25MB

Upload the back your insurance card

Maximum allowed size : 25MB
Nearest relative not living with you

First Name

Last Name

Relative Phone

Personal Payment Type

Who will be responsible for your account?

Guarantor Information

First Name

Last Name

Relative Phone

Date of birth

Social Security Number

Street Address 1

Street Address 2

Apt.

City

State

Zip

Employer/Business Name

Home Phone

Business Phone

Insurance information

General Insurance information

Employed

Marital status

Are you a student?

School Name

Primary Dental Insurance Subscriber

First Name

Last Name

Patients Relationship to Subscriber

Date of birth

Insured Party Gender

Insured Party Phone

Social Security Number

Insured Party Address 1

Insurance Party Address 2

City

State

Zip

Primary Dental Insurance Information

Employer / Business

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address 1

Insurance Company Address 2

City

State

Zip

Phone Number

Group Name

Group Number

Do you have secondary dental insurance?

Dental History

What is the reason for your visit?

Date of last dental visit

Last dental cleaning

Last full mouth X-rays

What was done at your last dental visit?

Previous dentist's name

Address

State

Zip

Telephone

How often do you have dental examinations?

How often do you brush your teeth?

How often do you floss?

What other dental aids do you use? (Interplak, toothpick, etc.)

Do you have any dental problems now?

Are any of your teeth sensitive to:

Hot or cold?

Sweets?

Biting or Chewing?

Have you noticed any mouth odors or bad tastes?

Do you frequently get cold sores, blisters or any other oral lesions?

Have you ever had:

Orthodontic treatment?

Oral Surgery?

Periodontal treatment?

Your teeth ground or the bite adjusted?

A bite plate or mouth guard?

A serious injury to the mouth or head?

Are your gums:

Do your gums bleed or hurt?

Have your parents or spouse experienced gum disease or tooth loss?

Have you noticed any loose teeth or change in your bite?

Does food tend to become caught in your teeth?

Have you experienced:

Clicking or popping of the jaw or pain? (joint, ear, side of face)

Difficulty in chewing on either side of the mouth?

Headaches, neckaches or shoulder aches?

Sore muscles (neck, shoulders)?

Are you satisfied with your teeth's appearance?

Would you like to keep all of your teeth all your life?

Do you feel nervous about dental treatment?

Do you:

Clench or grind your teeth while awake or asleep?

Bite your lips or cheeks regularly?

Hold foreign objects with your teeth? (pencils, pipe, pins, nails, fingernails)

Mouth breathe while awake or asleep?

Have tired jaws, especially in the morning?

E-Cigarette / Smoke / Chew Tobacco?

Is there anything else about having dental treatment that you would like us to know?

Health history

To our patients: Although periodontists 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 care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

What is your height? (in.)

What is your weight? (lbs.)

Are you in good health?

Have there been any changes in your general health in the past year?

Are you under the care of a physician?

Have you had any illness, operation or been hospitalized in the past five years?

Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?

Do you have a prosthetic joint/implant?

Have you had a heart valve replacement or vascular graft?

Have you ever had general anesthesia?

Have you, or a family member, had any unusual or serious reactions to general anesthesia?

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Is there any condition concerning your health that the doctor should be told about?

Do you wish to speak to the doctor privately about anything?

Who will be driving you home if surgery is required?

Mobile Phone

Notify of Pick-up status via

Is there a FAMILY history of

Cancer

Diabetes

Heart Disease

Anesthesia Problems

Autism

Health History Cont.
Have you had or do you currently have...

*Rheumatic fever

*Damaged heart valves/mitral valve prolapse

*Heart murmur

*High blood pressure

*Low blood pressure

*Chest pain/ angina

*Heart attack(s)

*Irregular heart beat

*Cardiac pacemaker

*Heart surgery

*Pneumonia, bronchitis or chronic cough

*Asthma

*Hay fever/sinus problems

*Snoring

*Sleep Apnea / CPAP

*Difficult breathing/other lung trouble

*Tuberculosis

*Emphysema

*Do you smoke or vape?

*Do you use marijuana?

*Do you use chewing tobacco?

*Blood transfusion

*Blood disorder such as anemia

*Bruise easily

*Bleeding tendency/ abnormal bleed

*Hepatitis, jaundice, or liver disease

*Infectious mononucleosis

*Gallbladder trouble

*HIV/AIDS

Have you had or do you currently have...

*Fainting spells

*Convulsions/ epilepsy

*Stroke

*Thyroid trouble

*Diabetes

*Low blood sugar

*Kidney trouble

*High cholesterol

*Are you on dialysis?

*Swollen ankles, arthritis or joint disease

*Osteoporosis/ osteopenia

*Osteonecrosis

*Stomach ulcers/ acid reflux

*Contagious diseases

*Sexually transmitted disease

*Problems with the immune system? Possibly from medication/ surgery, etc.

*Delay in healing

*A tumor or growth

*Cancer, radiation therapy or chemotherapy

*Chronic fatigue/ night sweats

*Are you on a diet?

*A history of alcohol abuse

*A history of drug use?

*Contact lenses

*Eye disease/ glaucoma

*Mental health problems/ anxiety/ depression

*Removable dental appliance

*Pain and clicking of jaws when eating

Pregnancy and Birth Control

Is there a possibility of pregnancy?

Expected delivery date?

Are you nursing?

Are you taking birth control pills?

Date of your last period?

Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other methods of birth control.

Medications Allergies
Medications (Are you now taking...)

Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil)

Have you ever taken diet pills

Any natural product, herbal supplement or homeopathic remedy

Are you taking, or have you ever taken bone density meds, RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, or Evista in the past 12 years?

Have you ever taken tranquilizers, sleeping pills, anti-depressants and/or narcotics on a regular basis. If yes, please list:

If you are under the care of a physician for pain management, or recovering from drug addiction please select the medication you are currently taking:

Methadone

Suboxone

Oxycodone

Fentanyl

Other

Other Description

Treating Doctor First Name

Treating Doctor Last Name

Are you allergic or had a reaction to:

Local anesthetic (numbing medication)

Penicillin

Other antibiotics

Sulfa Drugs

Sodium pentothal, Valium, or other tranquilizer

Aspirin

Amoxicillin

Codeine or other narcotics

Latex

Soy

Eggs/Yolk

Sulfites

Do you have any known allergies?

Please list any allergies other than drug allergies?

Are you taking any kind of medication, drug, pills?

Please list any other medications or antibiotics you are allergic to.

Medication / Antibiotic Allergy #1

Medication Name

Our Office Policy

To enable us to establish the best relationship with our patients and to avoid misunderstanding in the future, we have established certain office policies.

Each patient we treat is entitled to and will receive a thorough and careful examination. We are dedicated to the principle of doing our best in treating all patients with the highest quality treatment possible.

It is customary to pay for dental services when treatment is rendered unless prior written arrangements have been made. We accept Visa, MasterCard, American Express, & Discover with a 3% surcharge. We also participate with CareCredit and The Lending Club, which provide interest free financing ( interest accrues if terms not met please ask us for details). For our patients who have dental insurance, we will File your claim and request the payment be sent directly to us. You will be responsible for any portion not covered by your insurance at the time treatment is rendered. Some insurance policies will not assign benefits to out of network providers; in these cases, unfortunately we are unable to accept assignment of benefits. We will however file the claim for the insurance company to reimburse you directly. If a claim for which we have accepted assignment of benefits remains outstanding for more than 60 days or if we must appeal a negative decision on your behalf, you must pay the existing balance and we will reimburse you directly when the insurance company pays the claim.

Return checks will be subject to a returned check fee. Should your account need to be turned over for outside collection, a 35% collection fee will be incurred.

It is our office policy that 24 hours notice must be given if you are forced to cancel an appointment (Surgery appointments need 48 hours notice). A broken appointment fee may be charged and payment will be the patient's responsibility. After two broken appointments, we will place your file in an "inactive status" and special arrangements must be made to reactivate it.

*Signature

Consent

1. I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and any other diagnostic aids deemed necessary by the doctor to make a thorough diagnosis of my dental needs.

2. 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.

3. I consent to the use of appropriate medication and therapy as deemed necessary. I fully understand that using anesthetic agents embodies a certain risk.

4. Lastly, I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of services unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1.5% finance charge (18% APR) may be added to my account

*Patient

*Date

Witness

*Parent or Responsible Party

*Relationship to Patient

Acknowledgement of Receipt of Notice of Privacy Policies

I received a copy of the Notice of Privacy Practices of Northeast Florida Periodontics & Dental Implants. I hereby authorize, as indicated by my signature below, Northeast Florida Periodontics & Dental Implants to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose, as authorized in the Patient Consent form.

*Print Name

*Signature

*Date

Please check your preferred means of communication:

You may contact me at my home telephone number:
You may contact me at my mobile telephone number:
You may contact me at my work telephone number:
You may send me an email at:

Please list authorized persons with whom we may discuss your Protected Health Information (PHI). Please notify us if you desire to remove a name from this list in the future.

1.

Relationship

Date added/removed

2.

Relationship

Date added/removed

3.

Relationship

Date added/removed

HIPAA

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information.

This release is strictly designated to give permission to Dr. Roger D. Robinson Jr., DMD, MS, to use my digital patient photo series. I will allow these photos to be shared with other professionals and patients strictly in an educational setting in office and on various digital platforms (i.e. Company Facebook and website). Dr. Robinson will have permission to use these photos in the manner described above unless I request him to no longer use them. A written request form is available to do so. I understand that by allowing Dr. Robinson to use my photos, he is able to share "before and after" images to educate and explain procedures and possible results of treatment. I understand that I will not be compensated for the sharing of these photos. I understand that I have the option to decline this request, and am not obligated in any way to provide permission to use these photos.

I will allow Dr. Roger D. Robinson Jr., DMD, MS, to share my digital patient photos with other patients and/or professionals in an educational setting.

Full Photo Series (including full face shots)
Close Up Photos Only (no full face)

Patient Name

Signature (Parent/Guardian if under 18 years old)

*Date

--------------------------------------------------------------------------------------------------------------------------------------------------------------------------

I am denying/retracting permission for my photos to be shared with other patients/professionals.

Patient Name

Signature (Parent/Guardian if under 18 years old)

*Date

Conclusion
Emergency Contact Details

First Name

Last Name

Home Phone

Mobile Phone

Relationship to Patient

Accident

Is this related to an accident?

If Yes, What type?

Date of Injury

Insurance Company Handling This Claim

Insurance Claim Number

Name of Attorney / Adjustor

Attorney / Adjustor Phone