Adams Morgan Family Dentistry, PLLC PATIENT INFORMATION FORM Name __________________________________ Today’s Date _______________________________________________________ How do you wish to be addressed? _______________________________________________________________________________ Birth Date _______________ Sex ___________ Social Security No. ___________________________________________________ Home Address _______________________________________________________________________________________________ Home Phone _____________________________ Business Phone ____________________________________________________ Mobile __________________________________ E-Mail address ______________________________________________________ Occupation _____________________________ Employed by _______________________________________________________ Business Address ____________________________________________________________________________________________ Spouse _______________________________ Other family member in this practice ______________________________________ Who will pay this account? _____________________________________________________________________________________ Mailing address if different from above ____________________________________________________________________________ Who may we thank for referring you? _____________________________________________________________________________ Do you have dental insurance? __________________________________________________________________________________ Dental Insurance Name ________________________________________________________________________________________ ID No. __________________________________ Group No. _________________________________________________________ Dental Insurance Phone Number and Mailing Address ________________________________________________________________ ___________________________________________________________________________________________________________ Subscriber’s Name ________________________ Subscriber’s SSN ____________________________________________________ Subscriber’s DOB ____________________________________________________________________________________________ OVER MEDICAL HISTORY Patient Name _________________________________________________ Nickname_________________________ Age__________ Name of Physician ____________________________________________________________________________________________ Most recent physical examination _______________________________________ Purpose__________________________________ What is your estimate of your general health? Poor Fair Good HAVE YOU EVER HAD THE FOLLOWING: YES NO YES 1. hospitalization for illness or injury…………… 2. allergic to aspirin, ibuprofen, acetomenophen penicillin erythromycin tetracycline codeine local anesthetic fluoride metals (gold, stainless steel) latex any other medications__________________ 3. heart problems………………………………… 4. heart murmur………………………………….. 5. rheumatic fever……………………………….. 6. scarlet fever……………………………………. 7. high blood pressure…………………………… 8. low blood pressure……………………………. 9. a stroke…………………………………………. 10. artificial prosthesis (i.e. heat valve or joints) 11. anemia or other blood disorder……………… 12. prolonged bleeding due to a slight cut……… 24. 25. 26. 27. 28. 29. 30. 31. 32. 33. 34. 35. 36. 37. 38. 39. 40. 41. 42. 43. 13. emphysema……………………………………. 14. tuberculosis……………………………………. 15. asthma…………………………………………. 16. sinus problems………………………………… 17. kidney disease………………………………… 18. liver disease……………………………………. 19. jaundice………………………………………… 20. thyroid or parathyroid disease……………….. 21. hormone deficiency…………………………… 22. high cholesterol………………………………... 23. diabetes………………………………………… 44. 45. 46. 47. 48. 49. 50. 51. 52. 53. 54. stomach or duodenal ulcer………………………... digestive disorders…………………………………. arthritis………………………………….………….. glaucoma………………………………….……….. contact lenses………………………………….….. head or neck injuries……………………………… epilepsy, convulsions (seizures) ………………… viral infections and cold sores…………………… any lumps or swelling in mouth………………….. hives, skin rash, hay fever………………………… venereal disease…………………………………... hepatitis (type_____)……………………………… HIV / AIDS………………………………….………. tumor, abnormal growth…………………………... radiation therapy…………………………………... chemotherapy………………………………….…... emotional problems………………………………... psychiatric treatment……………………………… antidepressant medication……………………….. alcohol / drug dependency……………………….. NO ARE YOU: presently being treated for any illness…………... aware of a change in your general health………. often exhausted or fatigued………………………. subject to frequent headaches…………………… a heavy smoker (1 pack or more a day)………… considered a touchy person……………………… often unhappy or depressed……………………… easily upset or irritated……………………………. FEMALE – taking birth control pills……………… FEMALE – pregnant………………………………. MALE – Prostate disorders………………………. Please describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment ___________________________________________________________________________________________________________ List any medications, herbal supplements, and or vitamins taken within the last two years____________________________________ ___________________________________________________________________________________________________________ Please advise us in the future of any change in your medical history or any medications you may be taking. Patient’s Signature__________________________________________________________________ Date_____________________ OVER DENTAL HISTORY Referred by __________________________ How would you rate the condition of your mouth? Excellent Good Fair Poor Previous dentist _____________________________ How long have you been a patient? __________Months/Years Date of most recent dental exam _______/_______/________ Date of most recent dental X-Ray_______/________/_________ Date of most recent treatment (other than a cleaning) ________/________/________ I routinely see my dentist every: 3mo. 4mo. 6mo. 12mo. Not routinely WHAT IS YOUR IMMEDIATE DENTAL CONCERN?____________________________________________________________________ PLEASE ANSWER YES OR NO TO THE FOLLOWING: YES NO PERSONAL HISTORY 1. 2. 3. 4. 5. 6. Are you fearful of dental treatment? Scale of 1 to 10 (very) _____…………………………………………………………. Have you had an unfavorable dental experiences?.………………………………………………………………………….. Have you ever had complications .……………………………………………………………………………………………… Have you ever had trouble getting numb or reactions to local anesthetic? ………………………………………………… Did you ever have braces, orthodontic treatment or had your bite adjusted? ……………………………………………… Have you had any teeth removed? .…………………………………………………………………………………………….. SMILE CHARACTERISTICS 7. 8. 9. 10. Is there anything about the appearance of your teeth that you would like to change? …………………………………….. Have you ever whitened (bleached) your teeth: ……………………………………………………………………………….. Are you self conscious about your teeth: ……………………………………………………………………………………….. Have you been disappointed with the appearance of previous dental work: ……………………………………………….. BITE AND JAW JOINT 11. 12. 13. 14. 15. 16. 17. 18. 19. Do you / would you have any problems chewing gum? ……………………………………………………………………….. Do you / would you have any problems chewing bagels or other hard foods? …………………………………………….. Have your teeth changed in the last 5 years, become shorter, thinner or worn? ………………………………………….. Are your teeth crowding or developing spaces?……………………………………………………………………………….. Do you have more than one bite or do you clench (squeeze) to make your teeth fit together?…………………………… Do you have any problems with sleep or wake up with an awareness of your teeth? …………………………………….. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping) …………………………… Do you have tension headaches or sore teeth?………………………………………………………………………………… Do you wear or have you ever worn a bite appliance? ………………………………………………………………………... TOOTH STRUCTURE 20. 21. 22. 23. 24. Have you had any cavities within the past 3 years?……………………………………………………………………………. Do you have a dry mouth?………………………………………………………………………………………………………… Are any teeth sensitive to hot, cold, biting or sweets? …………………………………………………………………………. Have you ever had a toothache, cracked filling, broken, chipped or cracked tooth? ………………………………………. Do you avoid brushing any part of your mouth?………………………………………………………………………………… GUM AND BONE 25. 26. 27. 28. 29. 30. 31. Have you ever been diagnosed or treated for periodontal (gum) disease? …………………………………………………. Have you ever experienced gum recession? …………………………………………………………………………………… Is there anyone with a history of periodontal disease in your family? ………………………………………………………... Do your gums bleed when brushing, flossing or eating? ……………………………………………………………………… Are your teeth becoming loose? …………………………………………………………………………………………………. Have you ever noticed an unpleasant taste or odor in your mouth? ………………………………………………………… Have you experienced a burning sensation in your mouth? ………………………………………………………………….. Patient’s Signature_________________________________________________________________ Date________________________ Doctor’s Signature_________________________________________________________________ Date_________________________ ADAMS MORGAN FAMILY DENTISTRY PAYMENT POLICIES Below please find our office payment policies. Patients must agree to these terms in order to receive treatment. Please read and sign below. I. The Patient is Responsible for All Costs and Fees Full payment is expected at the time of service. We accept cash, money order, or credit/debit cards. We do not accept personal checks. We require a debit or credit card number to be placed on file for charges incurred and not paid by the patient, or the patient’s insurance carrier. You authorize Adams Morgan Family Dentistry, PLLC to apply any unpaid fees to your card. Card# __________________________ II. Exp. Date____/____/____ Sec. Code_____________ Dental Insurance of Third –Party Payers If you have dental insurance, we will accept your insurance as payment, and submit a claim to your insurance carrier. You must provide us with the insurance carrier and policy number prior to treatment. Often, insurance pays only a portion of your bill, or you must pay a co-pay. We can only provide you with an estimate of how much your insurance carrier will pay. This estimate is not binding on us or you. You, the patient, are responsible for any portion of your bill not paid for by insurance. Any overpayment or excess payment will be refunded. III. Cancellations Unlike some offices, we reserve treatment time especially for you. We don’t “double book” or book more patients than we can see. Should you need to cancel or change your appointment, you must do so two business days prior to your appointment, to avoid our mandatory cancellation fee of $50.00. This cancellation fee will be charged for any missed appointment, or any appointment cancelled later than two business days prior to treatment. This fee must be satisfied before we will schedule a new appointment. IV. Remedies for Unpaid Fees and Costs In the event that any patient balance remains unpaid after 30 days, you authorize us to charge your debit or credit card on file. In the event that the balance remains unpaid, we reserve the right to forward any outstanding balance to a collection agency or institute legal action or both. You agree to pay reasonable attorney fees or costs associated with any collection action. These financial policies help us keep the cost of administering dentistry affordable for you. Please assist us, as a partner in your dental health, by following our policies. Thank you, and welcome to our practice! I have read and understand this policy and agree to the above terms. ___________________________ _________________________ Patient name Relationship to patient (if a minor} ____________________________ _________________________ Signature of patient or responsible party Date Adams Morgan Family Dentistry, PLLC CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION SECTION A: PATIENT GIVING CONSENT Name: __________________________________ Address: ________________________________ Telephone: _____________________ E-mail: __________________________________ Social Security Number: ___________________ SECTION B: TO THE PATIENT – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY. Purpose of Consent: By signing this form you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practice, we will issue a revised Notice of privacy Practices which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Contact Person: Dr. Ilana Zukerberg Telephone: 202 667-0663 Address: 1790 Lanier Place N.W., Washington, D.C. 20009 Email: amfdent@yahoo.com Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contract Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent. I, ____________________________(print name)___ have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations. SIGNATURE: _______________________ Date: ____________ If this Consent is signed by a personal representative on behalf of the patient, complete the following: Personal Representative’s Name: ____________________ Relationship to Patient: _____________ Adams Morgan Family Dentistry, PLLC ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** I, _______________________________________, have received a copy of this office’s Notice of Privacy Practices. ________________________________________ {Please Print Name} ________________________________________ {Signature & Date} If this Acknowledgement is signed by a personal representative on behalf of the patient, complete the following: Personal Representative's name__________________________________________ Relationship to Patient__________________________________________________ For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: © 2005 American Dental Association All Rights Reserved Reproduction and use of this form by dentists and others involved in providing services is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association. This Form does not constitute legal advice and covers only federal law.