Dental appointments "*" indicates required fields 1Patient Registration 2Covid 19 Questions3Dental History Information4HIPAA Compliance Patient Consent5Payment Arragement Patient Registration First Name* MI Last Name* Nick Name* Home Phone*Work PhoneCell PhoneDate of birth MM slash DD slash YYYY Gender Male Female SS#Address Street Address City State Zip Employer State ID/Driver's License #E-mail Address* Name of Physician Physician PhoneIn case of Emergency Contact Relationship Phone:How did you hear about our office? Patient Health HistoryDo you have a history of:A.I.D.S/HIV Positive Yes No Alcoholism Yes No Allergies Yes No Anemia Yes No Arthritis Yes No Asthma Yes No Blood Disease Yes No Bone Disease Yes No Cancer Yes No Chemical Dependency Yes No Chest Pain Yes No Circulatory Problems Yes No Convulsions/Seizures Yes No Diabetes Yes No Excessive Bleeding Yes No Epilepsy Yes No Glaucoma Yes No Hay fever Yes No Header injuries Yes No Hearing Impaired Yes No Heart Disease Yes No Heart Valve, Murmur Yes No Hepatitis/Liver Disease Yes No Hepatitis Carrier Yes No High Blood Pressure Yes No Hip or Joint replacement Yes No HPV Yes No Jaundice Yes No Kidney Disease Yes No Kidney Dialysis Yes No Latex Sensitivity Yes No Lupus Yes No Low Blood Pressure Yes No Malignancies Yes No Mitral Valve Prolapse Yes No Neck & Back Problems Yes No Nervous Problems/Disorders Yes No Pacemaker Yes No Prosthetic Joints Yes No Psychiatric Care Yes No Radiation Treatment Yes No Respiratory Problems/Disorders Yes No Rheumatic Fever Yes No Rheumatism Yes No Scarlet Fever Yes No Seizures/Fainting spells Yes No Sinus Problems Yes No Stomach Ulcers Yes No Stroke Yes No Thyroid Disease Yes No Tuberculosis Yes No Tumors or growths Yes No Ulcers Yes No Venereal Disease Yes No Medical QuestionsList any medications you are taking including nonprescription drugsDo you have any disease/problem you think we should know about? Yes No Disease/problemAre you allergic to any medications? Yes No Allergic to medicationsAre you in good health? Yes No Date of the last medical exam MM slash DD slash YYYY Have you ever been hospitalized? Yes No Hospitalized problemHave you had a transplant operation that has depreseed your immune system? Yes No Do you smoke or chew tobacco? Yes No Have you had Heart Surgery? Yes No Are you now under the care of an MD? Yes No Are you taking or have you ever taken bisphosphonates? (Fosamax or Actonel for osteoporosis, chemotherapy, etc) Yes No Covid 19 QuestionsDate/Fecha* MM slash DD slash YYYY As a safety measure to our staff and other patients, we kindly ask that you answer the following questions:Do you have fever or experience fever within the past 14 days? Have you experienced a recent onset of respiratory problems, such as a cough, sore throat, difficulty in breathing, or any muscle pain or gastrointestinal problems within the past 14 days? Have you had, within the past 14 days foreign travel? Have you had any contact within the past 14 days with anyone who has traveled to China, Hong Kong, Macau, South Korea, Italy or Iran? Have you come in contact with a patient with confirmed 2019-nCov infection within the past 14 days? Are there at least two people with documented experience of fever or respiratory problems within the last 14 days having close contact with you? Have you recently participated in any gathering, meetings, or had close contact with many unacquainted people? I will not hold Bliss Dental accountable/liable if I get sick.(please initials) Como medida de seguridad para nuestro personal y otros pacientes, le rogamos que responda las siguientes preguntas: ¿Tiene fiebre o ha tenido fiebre en los ultimos 14 dias? ¿Ha experimentado una aparicion reciente de problemas respiratorios como tos, dolor de garganta, dificultad para respirar, dolor muscular o problemas gastrointestinales en los ultimos 14 dias? ¿Ha viajado al extranjero en los ultimos 14 dias? ¿Ha tenido algun contacto en los ultimos 14 dias con alguien que haya viajado a China, Hong Kong, Macao, Corea del Sur, Italia o Iran? ¿Ha entrado en contacto con un paciente con infeccion confirmada de 2019-nCoV en los ultimos 14 dias? ¿Hay al menos dos personas con experiencia documentada de fiebre o problemas respiratorios en los ultimos 14 dias que tengan contacto cercano con usted? ¿Ha participado recientemente en alguna reunion , fiesta o ha tenido contacto cercano con muchas personas desconocidas? Bliss Dental no va a ser responsable si yo me enfermo. (iniciales) Gracias por su cooperacion. Dental History InformationFor woman onlyAre you taking birth control pills? Yes No Are you nursing/breastfeeding? Yes No Are you pregnant? Yes No Expected delivery date MM slash DD slash YYYY Is there a possibility of pregnancy? Yes No NOTE: Antibiotics (such as penicillin) may alter the effect of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.Date of last dental visit? Name of your previous dentist Do you snore? Yes No Do you have problems with bad breath? Yes No Reason for today's visit? Have you ever had an allergic reactions to a crown, metal filling or dental appliance? Yes No Have you ever had an oral cancer screening? Yes No Have you ever used an electric toothbrush? Yes No How often do you floss your teeth? How important is your dental health to you? On a scale from 1 to 10, with 10 being the highestAre your teeth sensitive to hot, cold or pressure? Yes No Do your gums bleed when you brush? Yes No Have you ever had complications from an extraction? Yes No Are you prone to frequent headaches? Yes No Do you grind or clench your teeth? Yes No Do you have sores, blisters or swelling on your gums lips or cheeks? Yes No Have you ever had orthodontic treatment? Yes No Have you ever had a popping or clicking near your ear when you chew? Yes No Have you or a family member ever been treated for periodontal disease? Yes No If you could change something about your smile what would it be: Whiter Straighter Close space Replace black mercury filling with tooth colored restorations Repair chipped teeth Replace missing teeth Less gums showing Replace old crowns or caps that don't match I certify that I have read and understand the questions, above. I acknowledge that my questions have been answered to my satisfaction. I will not hold my dentist or any other members of his/her staff responsible for any errors that I have made in the completion of this form. Adult/Guardian: I hereby consent to the treatment indicated on my examination form, including the use of any anesthetics, sedatives, or x-rays, as may be deemed necessary by the doctor.Parent/Guardian (if patient is a minor) Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY HIPAA Compliance Patient ConsentOur Notice of Privacy Practices provides information about how we may use or disclose protected health information. The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent. The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date. You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive. By signing this form, I understand that: • Protected health information may be disclosed or used for treatment, payment, or healthcare operations. • The practice reserves the right to change the privacy policy as allowed by law. • The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions. • The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease. • The practice may condition receipt of treatment upon execution of this consent. May we phone, email, or send a text to you to confirm appointments? Yes No May we leave a message on your answering machine at home or on your cell phone? Yes No May we discuss your medical condition with any member of your family? Yes No If YES, please name the members allowed:Signature Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Witness Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY Payment ArragementPayment Agreement I agree that I am responsible for all services rendered to the Patient and that payment is due and payable to the Practice at the time services are rendered and that health, dental and accident insurance policies are an arrangement between my insurance carrier and me. I agree to pay all deductibles and co-pays at the time of service (if I have dual insurance coverage, my co-pay or deductible will be based on the primary coverage). I understand that while the Practice will file claims with my insurance company on my behalf, I remain responsible to the Practice for what is not paid by my insurance company. I also understand that if the Practice cannot verify insurance benefits eligibility for me prior to treatment that I will pay in full for the services at the time they are rendered. I understand that the Practice may charge: 1) a late fee if payment on my account is not received by the due date; 2) an amount equal to $35.00, but not to exceed the maximum amount permitted by law for each returned check, and 3) a fee of $50.00 for each appointment that is missed/canceled without at least 24 hours advance notice. I agree to the extent permitted by law, that if my account balance is referred to any agency or attorney(s) for collection purposes, to pay reasonable attorney's fees and any expenses or costs relating to the collection proceeding, including court costs. I understand that if treatment or care is suspended at any time by the patient, all fees for professional services rendered will be immediately due and payable. I authorize payment directly to the Practice.Insurance InformationPrimary Insurance Name Phone NumberName of Insured DOB MM slash DD slash YYYY Relationship ID Number Group Number I acknowledge having received a copy of the Practice's Notice of Privacy Practices. I agree that a photocopy of this authorization is as valid as the original.Signature of Responsible Party Reset signature Signature locked. Reset to sign again Date MM slash DD slash YYYY (To be signed even if Patient is also the Responsible Party)EmailThis field is for validation purposes and should be left unchanged. Δ
