Ridge Crest Periodontics - Ridge Crest Periodontics

Demographic Information
Insurance information
Health History
Health History Cont.
Medications Allergies
Conclusion

Patient information

Prefix

*First Name

Middle Name

*Last Name

*Date of birth

*Social Security Number

*Email

*Gender

Male Female

*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?

Yes No

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

Yes No

Dentist Name

*Do you have a dentist?

Yes No

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

Cash Check Credit card

Who will be responsible for your account?

Other Information

Other Description

First Name

Last Name

Date of birth

Social Security Number

Home Phone

Mobile Phone

Street Address 1

Street Address 2

Apt.

City

State

Zip

Employer/Business Name

Home Phone

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?

Full-Time Part-Time Not a Student

School Name

Do you have dental insurance?

Yes No

Primary Dental Insurance Subscriber

*Subscriber First Name

*Subscriber Last Name

*Patients Relationship to Subscriber

*Subscriber Date of birth

Insured Party Gender

Male Female

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?

Yes No

Secondary Dental Insurance Subscriber

*First Name

*Last Name

*Patients Relationship to Subscriber

*Date of birth

*Insured Party Gender

Male Female

*Insured Party Phone

Social Security Number

*Insured Party Address 1

Insurance Party Address 2

*City

*State

*Zip

Secondary 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

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?

Yes No

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

Yes No

*Are you under the care of a physician?

Yes No

Physician Name

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

Yes No

If so, describe

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

Yes No

If so, describe

*Do you have a prosthetic joint/implant?

Yes No

If so, describe

*Have you had a heart valve replacement or vascular graft?

Yes No

If so, describe

*Have you ever had general anesthesia?

Yes No

If so, describe

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

Yes No

If so, describe

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

Yes No

If so, describe

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

Yes No

If so, describe

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

Yes No

If so, describe

Is there a FAMILY history of

*Cancer

Yes No

*Diabetes

Yes No

*Heart Disease

Yes No

*Anesthesia Problems

Yes No

*Autism

Yes No

Health History Cont.

Have you had or do you currently have...

*Rheumatic fever

Yes No

*Damaged heart valves/mitral valve prolapse

Yes No

*Heart murmur

Yes No

*High blood pressure

Yes No

*Low blood pressure

Yes No

*Chest pain/ angina

Yes No

*Heart attack(s)

Yes No

*Irregular heart beat

Yes No

*Cardiac pacemaker

Yes No

*Heart surgery

Yes No

*Pneumonia, bronchitis or chronic cough

Yes No

*Asthma

Yes No

*Hay fever/sinus problems

Yes No

*Snoring

Yes No

*Sleep Apnea / CPAP

Yes No

*Difficult breathing/other lung trouble

Yes No

*Tuberculosis

Yes No

*Emphysema

Yes No

*Do you smoke or vape?

Yes No

If so, how much a day?

*Do you use marijuana?

Yes No

*Do you use chewing tobacco?

Yes No

*Blood transfusion

Yes No

*Blood disorder such as anemia

Yes No

*Bruise easily

Yes No

*Bleeding tendency/ abnormal bleed

Yes No

*Hepatitis, jaundice, or liver disease

Yes No

*Infectious mononucleosis

Yes No

*Gallbladder trouble

Yes No

*HIV/AIDS

Yes No

Have you had or do you currently have...

*Fainting spells

Yes No

*Convulsions/ epilepsy

Yes No

*Stroke

Yes No

*Thyroid trouble

Yes No

*Diabetes

Yes No

*Low blood sugar

Yes No

*Kidney trouble

Yes No

*High cholesterol

Yes No

*Are you on dialysis?

Yes No

*Swollen ankles, arthritis or joint disease

Yes No

*Osteoporosis/ osteopenia

Yes No

*Osteonecrosis

Yes No

*Stomach ulcers/ acid reflux

Yes No

*Contagious diseases

Yes No

*Sexually transmitted disease

Yes No

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

Yes No

*Delay in healing

Yes No

*A tumor or growth

Yes No

*Cancer, radiation therapy or chemotherapy

Yes No

*Chronic fatigue/ night sweats

Yes No

*Are you on a diet?

Yes No

*A history of alcohol abuse

Yes No

*A history of drug use?

Yes No

*Contact lenses

Yes No

*Eye disease/ glaucoma

Yes No

*Mental health problems/ anxiety/ depression

Yes No

*Removable dental appliance

Yes No

*Pain and clicking of jaws when eating

Yes No

Pregnancy and Birth Control

*Is there a possibility of pregnancy?

Yes No

*Expected delivery date?

*Are you nursing?

Yes No

*Are you taking birth control pills?

Yes No

*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

What Medications Are You Taking Now?

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

Yes No

*Have you ever taken diet pills

Yes No

*Any natural product, herbal supplement or homeopathic remedy

Yes No

*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?

Yes No

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

Yes No

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

Yes No

*Suboxone

Yes No

*Oxycodone

Yes No

Fentanyl

Yes No

*Other

Yes No

Other Description

Treating Doctor First Name

Treating Doctor Last Name

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

Yes No

Please list any medications you are currently taking

Medication #1

Medication Name

Dosage

Frequency

Medication #2

Medication Name

Dosage

Frequency

Medication #3

Medication Name

Dosage

Frequency

Medication #4

Medication Name

Dosage

Frequency

Medication #5

Medication Name

Dosage

Frequency

Medication #6

Medication Name

Dosage

Frequency

Medication #7

Medication Name

Dosage

Frequency

Medication #8

Medication Name

Dosage

Frequency

Medication #9

Medication Name

Dosage

Frequency

Medication #10

Medication Name

Dosage

Frequency

Are you allergic or had a reaction to:

*Local anesthetic (numbing medication)

Yes No

*Penicillin

Yes No

*Other antibiotics

Yes No

Sulfa Drugs

Yes No

*Sodium pentothal, Valium, or other tranquilizer

Yes No

*Aspirin

Yes No

*Amoxicillin

Yes No

*Codeine or other narcotics

Yes No

*Latex

Yes No

*Soy

Yes No

*Eggs/Yolk

Yes No

*Sulfites

Yes No

*Do you have any known allergies?

Yes No

Please list any allergies other than drug allergies?

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

Medication / Antibiotic Allergy #1

Medication Name

Medication / Antibiotic Allergy #2

Medication Name

Medication / Antibiotic Allergy #3

Medication Name

Medication / Antibiotic Allergy #4

Medication Name

Medication / Antibiotic Allergy #5

Medication Name

Medication / Antibiotic Allergy #6

Medication Name

Medication / Antibiotic Allergy #7

Medication Name

Medication / Antibiotic Allergy #8

Medication Name

Medication / Antibiotic Allergy #9

Medication Name

Medication / Antibiotic Allergy #10

Medication Name

Conclusion

Emergency Contact Details

*First Name

*Last Name

Home Phone

*Mobile Phone

*Relationship to Patient

Accident

*Is this related to an accident?

Yes No

*If Yes, What type?

Automobile Work Related Other

*Date of Injury

*Insurance Company Handling This Claim

*Insurance Claim Number

*Name of Attorney / Adjustor

*Attorney / Adjustor Phone

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

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

Authorization for Service

I authorize my surgeon and his 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 (Patient or Legal Guardian)

*Date

Notice of Privacy Practices

I hereby acknowledge that Ridge Crest Implants & Periodontics maintains compliance with HIPAA regulations and that information regarding its privacy practices is available upon request.

*Sign

*Date

Authorization for Patient Communication

At Ridge Crest Periodontics, we recognize that electronic communication is convenient for our patients. It is important our patients understand that today’s electronic environment is highly susceptible to breaches, hacking, and the possibility of others viewing communications at home or at your place of work. This is why healthcare privacy laws regarding communication are in place.

We need additional permission if you would like us to communicate your individual or protected health information electronically, including automatic text reminders, in either of the following ways:

Text Messaging (Weave and DSN)

*These are our in office texting systems. These applications meet requirements of healthcare privacy laws the way we use them. However, depending on your phone settings, others may see notification banners indicating we have texted you, and if you give others access to your phone, they may be able to access your messages. I understand the potential risks of text messaging and want to use it anyway.

Yes No

Secure Email

Email is generally not considered secure without using encryption. We use secure email applications such as Identillect to meet requirements of healthcare privacy law. I understand the potential risks of using email and want to use it anyway.

Yes No

*For my convenience, I, the undersigned, wish to use the above selected communications with Ridge Crest Periodontics as indicated by my initials. I understand and accept the risks of electronic communication regardless of attempts to make them secure by healthcare privacy law standards.

*Sign

Date

Authorization for Photo Consent

I authorize Dr. Ethan Moulton, DDS, MS to take photographs and/or videos of my face, jaws, and teeth before, during, and after treatment. I consent to allow the photographs to be used for dental research, education, and marketing materials, including websites and printed materials.

I further understand that if the photographs and/or videos are used in any publication or demonstration, my identifying information (first name only) could be used unless stated differently below. I do not expect compensation, financial or otherwise, for the use of these photographs.

*Please Check One Option:

I do not mind if my photographs are used in any of the above stated situations. I only agree to have my teeth shown without any identifying features. I do not want my photographs used for any of the above purposes.

*Sign

Date

Consent for AI Assisted Clinical Documentation

Our office uses an artificial intelligence (AI) system to assist with creating and organizing clinical notes. This technology helps improve efficiency and accuracy in documentation so that providers can focus more time on patient care.

What This Means:

• The AI system may process audio or text from your visit to help draft or organize your clinical notes.

• Your provider reviews, edits, and approves all documentation before it becomes part of your medical record.

• The AI system does not make diagnoses, treatment decisions, or clinical judgments.

• All information processed by the AI system is handled securely and in compliance with HIPAA and applicable privacy laws.

• Your information is not shared outside of your care team and is not used for marketing or unrelated purposes.

*Consent (choose one option):

I consent to the use of AI assisted clinical documentation. I do not consent and request manual documentation instead.

*Sign

Date

Ridge Crest Periodontics - Patient Form

Patient information

Dentist Name

Orthodontist Name

Medical Doctor Name

Who were you referred by?

Nearest relative not living with you

Other Information

Guarantor Information

Insurance information

Primary Dental Insurance Subscriber

Primary Dental Insurance Information

Secondary Dental Insurance Subscriber

Secondary Dental Insurance Information

Health history

Is there a FAMILY history of

Health History Cont.

Have you had or do you currently have...

Have you had or do you currently have...

Pregnancy and Birth Control

Medications Allergies

What Medications Are You Taking Now?

Please list any medications you are currently taking

Are you allergic or had a reaction to:

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

Conclusion

Emergency Contact Details

Accident

Verification

FEES & PAYMENTS

Release of Information

Authorization for Service

Notice of Privacy Practices

Authorization for Patient Communication

Authorization for Photo Consent

Consent for AI Assisted Clinical Documentation