PATIENT INFORMATION
Completion of this information in its entirety is required at time of visit
Today’s Date ______________________
Date of Birth___ /___/___ Male/Female
Patient Name________________________________
First
Middle
Last
Nickname__________________
Home Phone_________________ Cell ______________
Email__________________
Address_________________________________________________________________
Number and Street
City
State
Zip
Person responsible for account ______________________________
Relationship ____________ Preferred Contact Phone Number_____________________
Patient currently lives with: Mother__ Father __ Both __ Other ______________
Father’s Name
Father’s DOB
Address
City, State, Zip
Home Phone
Cell Phone
Marital Status
Mother’s Name
Mother’s DOB
Address
City, State, Zip
Home Phone
Cell Phone
Marital Status
Employer
Work Phone
Email Address
Employer
Work Phone
Email Address
DENTAL INSURANCE
Insurance Company _______________________________ Phone Number___________
Group Number _____________ Insured ID Number _____________________________
Subscriber Name__________________ Subscriber Date of birth _______________
DENTAL HISTORY
Any pain or discomfort with teeth, gums or bite at the present time? _________________
If yes, what areas________________________________
Last visit to a dentist? _________________
Last dental x-rays? _____________________
Has a dentist or hygienist ever shown you how to properly clean your teeth? _____
Home care routine: Brush 1x daily _ Brush 2x daily _ Floss daily _ Mouth rinse _
HEALTH HISTORY
Does your child have regular medical exams? __________________________________
Is your child up to date with immunizations? __________________________________
Is your child presently undergoing medical treatment? ___________________________
Is your child presently taking any medications? _________________________________
Has your child experienced any unfavorable reactions to medications? ______________
Has your child ever been hospitalized? ________________________________________
Does your child have any emotional, mental, or nervous disorders? ________________
Is your child allergic to anything? ____________________________________________
Antibiotics __ (penicillin) Dental Anesthetics __ Codeine __ Other Meds __
Y N
Abnormal Bleeding
AIDS
Anemia
Arthritis
Asthma
Autism
Birth Defects
Bladder Disease
Blood Disorders
Brain Damage
Cancer/tumors
Cerebral Palsy
Chicken Pox
Chronic Headaches
Chronic Sinusitis
Convulsions/Seizures
Depression
Diabetes
Down syndrome
Eating Disorders
Epilepsy
Fainting
Frequent earaches
Hearing Disorders
Heart Disease
Y N
Heart Murmur
Hemophilia
Hepatitis
High Blood Pressure
HIV
Hyperactivity / ADHD
Kidney Disease
Liver Disease
Mental Retardation
Mononucleosis
Mumps
Poor Coordination
Respiratory Disease
Rheumatic Fever
Sensory Disorder
Sickle Cell Disease
Sight Disorders
Spina Bifida
STDs
Substance Abuse
Thyroid Condition
Tuberculosis
Any other conditions:
Please read and sign:
I give consent to Marc F. Bianco, D.M.D. or hygienist in charge of the care of the patient,
whose name is specified at the beginning of this form, to administer any treatment or
anesthetics, and to perform such dental services as may be deemed necessary or advisable
in the diagnosis and treatment of this patient. X__________________________________
Review Date
Comments
Review Date
Comments
PATIENT CONSENT FORM
Marc F. Bianco D.M.D.
1133 S.E. 122nd
Portland, OR 97233
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
understand that this information can and will be used to:
-
-
Conduct, plan and direct my treatment and follow-up among the multiple
healthcare providers who may be involved in that treatment directly and
indirectly.
Obtain payment from third-party payers.
Conduct normal healthcare operations such as quality assessments and
physician certifications.
I have been informed by you of your Notice of Privacy Practices containing a more
complete description of the uses and disclosures of my health information. I have been
given the right to review such Notice of Privacy Practices prior to signing this consent.
I understand that this organization has the right to change its Notice of Privacy Practices
from time to time and that I may contact this organization at any time at the address
below to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is
used or disclosed to carry out treatment, payment or health care operations. I also
understand you are not required to agree to my requested restrictions, but if you do agree
then you are bound to aide by such restrictions.
I understand that I may revoke this consent in writing at any time, except to the extent
that you have taken action relying on this consent.
Patient Name: ___________________________________________________________
Signature: ______________________________________________________________
Relationship to Patient: ____________________________________________________
Date: _________________________