PATIENT INFORMATION FORM
Name __________________ MI ___ Last Name _____________________
Address ____________________________________ City ___________
State _______ Zip Code ________ Sex: M
F
D.O.B.: ______________
S.S. # ____-____-____
E-mail ______________________
Home Phone # _________________
Mobile # _____________________
Work Phone # _________________
Driver’s License # ________________
Grisel Rincon, DDS
1730 W Fullerton Ave, Ste. #26
Chicago, Il 60614
ACCOUNT INFORMATION Relation to Patient: Self Spouse Parent Guardia Occupation __________
Full name __________________ Address _______________________ City __________
Home Phone # _________________ Mobile # _________________ S.S. # ____-____-____
Phone (773) 281-3000
Fax (773) 281-3033
DENTAL INSURANCE COMPANY ______________ Employer __________________ S.S. # ____-____-____
Subsrciber’s Name _________________ D.O.B. ______________
,-------- - ----- DENTAL INFORMATION ------ ---- --------,
Do your gums bleed when you brush?
Yes No
Do you have any fear of dental work?
Yes No
Are your teeth sensitive to heat or cold?
Yes No
Do you grind or clench your teeth?
Yes No
Presssure
Yes No
Sweets
Yes No
How would you describe your current dental problems? _________________________________________
_______________________________________________________________________
,-------- - ----- MEDICAL INFORMATION ------ ---- --------
1. Are you under medical care?
Yes No
2. Are you sensitive or allergic to any medication or anesthetics? _____________________________________
3. Indicate which of the following you have had or have at present. Circle Yes or No
Smoke
Drink
Recreational Drugs
AIDS
Allergies or Hives
Anxiety Problems
Arthritis, Rheumatism
Artificial Heart Valves
Artificial Joints
Asthma
Back Problems
Blood Disease
Cancer
Chemical Dependency
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
YES NO
Chemotherapy
Circulatory Problems
Cold Sores
Cortisone Treatments
Cough, Persistent
Cough up Blood
Diabetes
Epilepsy
Fainting
Glaucoma
Headaches
Heart Murmur
Heart Problems
Hemophilia
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Hepatitis
High Blood Pressure
HIV Positive
Jaw Pain
Kidney trouble
Latex Sensitivity
Liver Disease
Mitral Valve Prolapse
Neurological Problems
Pacemaker
Psychiatric Care
Radiation Treatment
Rheumatic Fever
Scarlet Fever
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
YES
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
NO
Shortness of Breath
YES NO
Sinus Problems
YES NO
Skin Rash
YES NO
Stroke
YES NO
Swelling of Feet/Ankles YES NO
Thyroid Problems
YES NO
Tobacco Habit
YES NO
Tonsillitis
YES NO
Tuberculosis
YES NO
Ulcers
YES NO
Venereal Disease
YES NO
Other:______________
Other:______________
Other:______________
Have you had Surgery or been hospitalized in the last 5 years? If yes, please describe ___________________________
________________________________________________________________________
WOMEN: Are you or have any suspicious of being pregnant? Yes No Nursing? Yes No Are you under Birth Control? Yes No
Dentist’ Signature ____________________________
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GENERAL DENTISTRY INFORMED CONSENT
Dentist:
Patient:
1. WORK TO BE DONE: I understand that I am having the following work done: Fillings ( ), Bridges ( ), Crowns ( ), X-rays ( ),
Extractions ( ), Impacted teeth removed ( ), Root Canals ( ), Dentures ( ), Other
(Initials- --'
2. DRUGS AND MEDICATION: I understand that antibiotics, analgesics and other medications can cause allergic reactions causing
redness and swelling of tissue, pain, itching, vomiting, and/or anaphylactic shock.
(Initials------'
3. CHANGES IN TREATMENT PLAN: I understand that during treatment it may be necessary to change or add procedures because of
conditions found while working on the teeth that were not discovered during examination. For example, root canal therapy following
routine restorative procedures. I give my pennission to my dentist to make any/all changes and additions as necessary. (Initials---'
4. REMOVAL OF TEETH: Alternatives to removal have been explained to me (root canal therapy, crowns, periodontal surgery, etc.)
And I authorize the dentist to remove the following teeth:
and any others necessary for reasons in
paragraph #3. I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further
treatment. I understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection, dry socket,
loss of feeling in my teeth, lips tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time or fractured jaw.
I understand I may need further treatment by a specialist if complications arise during or following treatment, the cost for which is my
responsibility.
(Initials----'
5. CROWNS, BRIDGES, AND CAPS: I understand that sometimes it is not possible to match the color of natural teeth exactly with
artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to
ensure that tl1ey are kept on until the permanent crowns are delivered. I realize the final opportunity to make changes in my news crown
bridge, or cap (including shape, fit, and color) will be before cementation. It is also my responsibility to return for permanent cementation
within 21 days from toot11 preparation. Excessive delays may allow for tooth movement. This may necessitate a remake oftl1e crown,
bridge, or cap. I understand that there will be additional charges for remakes due to my delaying permanent cementation.
(Initials
,
6. ENDODONTIC TREATMENT (ROOT CANAL): I realize there is no guarantee tlmt root canal tl1erapy will save my tooth, and that
complications can occur from tl1e treatment, and that occasionally root canal filling material may extend tlrrough the tooth which does not
necessarily effect tl1e success of the treatment. I understand that endodontic files are very fine instruments and stresses from their
manufacture can cause them to separate during use. I understand that occasionally additional surgical procedures may be necessary
following root canal treatment (apicoectomy). I understand that the tooth may be lost in spite of all efforts to save it. (Initials--7. PERIODONTAL LOSS (TISSUE AND BONE): I understand tl1at I have a serious condition, causing gum and bone inflamation or
loss and tha t it can lead to the loss of my teeth. Alternative treatment plans have been explained to me, including gum surgery,
replacements and/or extractions. I understand that undertaking any dental procedure may have a future adverse effect on my
periodontal condition.
(Initials
,
8. FILLINGS: I understand t11at care must be exercising in chewing on fillings especially during tl1e first 24 hours to avoid breakage.
understand that a more extensive filling than originally diagnosed may be required due to additional decay. I understand that significant
sensitivity is a common after effect of a newly placed filling.
(Initials
,
9. DENTURES: I understand tl1e wearing of dentures is difficult. Sore spots, altered speech, and difficulty in eating are some common
problems. Immediate dentures (placement of denture in1111ediately after extractions) may be painful. Immediate dentures may require
considerable adjusting and several relines. A permanent reline will be needed later. This is not included in the denture fee. I understand
that it is my responsibility to return for delivery of the dentures. I understand that failure to keep my delivery appointment may result in
poorly fitted dentures. If a remake is required due to my delays of 30 days, tl1ere will be additional charges.
(Initials- - ---'
I understand that dentistry is not an exact science and tl1at therefore, reputable practitioners cannot properly guarantee results.
acknowledge tl1at no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and
authorized.
I hereby autl1orize any of the doctors or dental auxiliaries to proceed witl1 and perfonn the dental restorations and treatments as explained to
me. I understand that tl1is is only an estimate and subject to modification depending on unforseen or undiagnosable circumstances that may
arise during tl1e course of treatment. I understand t11at regardless of any dental insurance coverage I may have, I am responsible for payment
of the dental fees. I agree to pay any attorney 's fees, or court costs, that may be incurred to satisfy this obligation.
Signature of Patient
______________________
Date:
Signature of Dentist
_______________________________
Date:
www.RiverpointDentalCenter.net
_____________
_____________________
State of Illinois
Department of Healthcare and Family Services
AUTHORIZATION TO DISCLOSE HEALTH INFORMATION
NOTICE:
• Federal law says that Healthcare and Family Services (HFS) cannot share your health information without
your permission except in certain situations. If you sign this form, you are giving HFS permission to share
your health information that HFS has with the person you indicate below.
• This authorization is voluntary.
• Right to revoke : If you decide you do not want HFS to share your health information any longer, sign the
revocation at the end of this form and give this form to HFS. If HFS has shared your health information
for a research study, HFS may continue to use or share your health information for that purpose only.
• Payment, enrollment or eligibility for benefits for your health care will not be affected if you do not sign
this authorization, unless the disclosure is for eligibility or enrollment determinations, or for risk
determinations.
• HFS cannot promise that the person you permit HFS to share your health information with will not share your
health information with someone else you may not want to have your health information.
• You can keep a copy of this authorization, and can contact the HFS
privacy officer to get a copy if you do not have one.
My name (print)
Date of Birth
Social Security Number
Recipient I.D. Number
I give permission to: Healthcare and Family Services to share my health information with:
so that this person or entity may assist me with my health care issues.
HFS may share my health information for one year after the date on this authorization form or until I revoke
the authorization.
I want HFS to share this health information: (check all boxes that apply)
All of my health information
Information regarding prescription drug coverage
My health information regarding Acquired Immunodeficiency Syndrome (AIDS)
or Human Immunodeficiency Virus (HIV)
My health information regarding treatment for alcohol and/or substance abuse
My health information regarding behavioral health services or psychiatric care
Other
This form must be signed by EITHER the recipient OR by the personal representative. The recipient's
parent may sign for the recipient if the recipient is a minor.
Signature of Recipient
Date
Relationship of personal representative
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Request For Confidential Communication
Name:
SSN:
DOB:
Primary Physician:
Date of Request:
I hereby request to receive confidential communications from the practice in the following manner:
Alternative phone number where I wish to be contacted:
Alternative address where I would like my protected health information mailed to me:
Street:
City:
State
Zip
Other confidential communication request:
You may leave limited protected health information on my voicemail or answering machine (lab or test results, information about
scheduling or prep for a test or procedure, or information regarding follow up with specialists).
YES
NO
You may communicate my protected health information with a family member:
YES
NO
If yes, please list family member(s):
Effective Date:
I also understand that my protected health information may be released as my physician determines appropriate in an
emergency.
Signature of the Patient:
Signature of Guarantor:
(Sign If Patient Is A Minor)
The Health Insurance Portability and Accountability Act of 1996 requires that health care providers offer patients a copy of the
office Notice of Privacy Practices and make a good faith effort to obtain an acknowledgment of receipt of same. You may refuse
to sign this acknowledgment form.
By signing this form, I confirm that I have been offered the office Notice of Privacy Practices.
Print Name:
Sign Name:
Date:
FOR OFFICE USE ONLY
I attempted to obtain the patient’s signature in acknowledgement on this Notice of Privacy Policy Acknowledgement, but was
unable to do so as documented below:
Date:
Initials:
Reason:
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