DSNForms

Prescott Periodontics & Implant Dentistry - Patient Form

Patient information

*First Name

Middle Inital

*Last Name

*Date of birth

Social Security Number

Email

Primary Phone Number

*Gender

Street Address

Apt.

City

State

Zip

Employed

Employer

Occupation

Have you ever been a patient of our practice?

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

Emergency Contact Details

First Name

Last Name

Home Phone

Mobile Phone

Relationship to Patient

Dentist 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

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

City

State

Zip

First Name

Last Name

Date of birth

Primary Dental Insurance Information

Employer / Business

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address 1

Ins. Company Address 2

City

State

Zip

Phone Number

Group Name

Group Number

Do you have secondary dental insurance?

Health history

To our patients: Although oral surgeons 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 reason for visiting our practice?

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?

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

Health History Cont.
PLEASE INDICATE THOSE CONDITIONS THAT YOU HAVE OR HAVE HAD IN THE PAST:

-Cardiovascular

*Angina (Chest Pain)

*Damaged heart valves/mitral valve prolapse

*Heart attack(s)

*Heart murmur

*Heart surgery

*High blood pressure

*High cholesterol

*Irregular heart beat

*Cardiac pacemaker

*Rheumatic fever

*Stroke

-Hematologic

*Abnormal bleed

*Anemia

*Blood transfusion

*Bruise easily

*Hemophilia

*Lukemia

*Sickle Cell Anemia

-Respiratory

*Asthma

*COPD

*Difficult breathing/other lung trouble

*Emphysema/Bronchitis

*Lung Disease

*Sleep Apnea / CPAP

-Endocrine

*Diabetes

*Thyroid trouble

-Renal

*Kidney trouble

*Are you on dialysis?

-Immune

*Immunosuppressive Disease

*Past Use Of Steroids

*Delay in healing

*Sjogren’s Syndrome

*Gallbladder trouble

-Infectious Diseases

*HIV/AIDS

*Sexually transmitted disease

.

-Musculoskeletal

*Arthritis

*Artificial joint

*Back problems

*Chronic fatigue syndrome

*Fibromyalgia

*Lupus

*Osteoporosis

-Gastrointestinal

*Acid reflux / GERD

*Chronic diarrhea

*Crohn’s Disease

*Irritable Bowel Syndrome

*Stomach Ulcer

-Hepatic

*Hepatitis, jaundice, or liver disease

*Jaundice

*Liver disease

-Neurologic

*Alzheimer’s Disease

*Cerebral Palsy

*Dementia

*Epilepsy

*Fainting spells / Dizziness

*Headaches

*Multiple Sclerosis

*Parkinson’s Disease

*Seizures

-Skin

*Hives or Skin Rash

*Skin Disorders

-Eyes / Ears

*Glaucoma

*Impaired Hearing

*Impaired Vision

-Mental Health

*Anxiety/ depression

*Bipolar Disorder

*Eating Disorder

-Other

*Cancer

*Radiation Treatment

*A history of alcohol abuse

*Chemical Dependency

*Recreational drug use?

*Tuberculosis

*Sinus problems

*Tobacco use

Pregnancy and Birth Control

Is there a possibility of pregnancy?

Expected delivery date?

Are you nursing?

Are you taking birth control pills?

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)

Are you taking, or have you ever taken a GLP-1 medication?

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?

Are you allergic or had a reaction to:

Local anesthetic (numbing medication)

Penicillin

Other antibiotics

Sulfa Drugs

Sodium pentothal, Valium, or other tranquilizer

Aspirin

Codeine or other narcotics

Latex

Do you have any known allergies?

Please list any allergies not listed?

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

Conclusion
Verification

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

FEES & PAYMENTS

We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

Release of Information

This signature on file is my authorization for the release of information necessary to process my claim. Reimbursement will go to PT.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

Authorization for Service

I authorize my surgeon and her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x–rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages to be left on my phone and / or mobile phone concerning my appointment.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

Notice of Privacy Practices

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.