Health History Form

Full Name:

Date of Birth:

Address:

Social Security #:

Drivers License #:

Home Phone:

Cell Phone:

Business Phone:

Email:

Employed by:

Occupation:

Business Address:

Have dental insurance through your job?:

How long have you worked there?:

Insurance Company:

Union:

Policy #:

Spouse's Name:

DOB:

Spouse SSN:

Spouse Employer:

Occupation:

Dental Insurance through spouse?:

How long has spouse worked there?:

Insurance Company:

Union:

Policy #:

Family Dentist:

City:

Date of last visit:

How long have you been there patient?:

Who referred you here?:

Emergency Contact:

Phone:

Your general health constitutes an important factor, and in combination with other causes, may influence the course of periodontal disease. To assure your health during therapy and to assist in establishing a thorough diagnosis for successful treatment, please complete this confidential form.

Physician:

City:

Phone:

Approximate date of last physical examination:

Please check the appropriate box in answer to the following questions.

Are you in good health?

Yes

No

?

If no, what is the nature of your illness?:

Are you now being treated by a physician?

Yes

No

?

If yes, what for?:

Are you taking any drugs or medication?

Yes

No

?

If yes, what?:

Have you ever been hospitalized?

Yes

No

?

If yes, when and what for?:

Have you ever had excessive bleeding requiring special treatment?

Yes

No

?

Do you have diabetes?

Yes

No

?

Has anyone in your family ever had diabetes?

Yes

No

?

If yes, who?:

Have you ever experienced continuous excessive thirst or frequent night-time urination?

Yes

No

?

Have you lost weight (with good appetite)?

Yes

No

?

Do injuries or cuts heal very slowly?

Yes

No

?

Does your mouth frequently seem dry?

Yes

No

?

Do you consider yourself to be under mental or emotional stress?

Yes

No

?

Do you smoke?

Yes

No

?

If yes, how much per day?:

How many servings of alcoholic beverages do you have in a week?:

(For females) are you pregnant?

Yes

No

?

If yes, how long?:

Have you ever had any of the following?

Have you become sick from, shown an allergy to, or been told not to take:

Antibiotics

Yes

No

Codeine

Yes

No

Novocaine, xylocaine, other dental anesthetics

Yes

No

Penicillin

Yes

No

Aspirin

Yes

No

Demerol

Yes

No

Other (please specify):

Are you now taking any of the following:

Hormones (including birth control pills)

Yes

No

Dilantin

Yes

No

Anticoagulants

Yes

No

Tranquilizers

Yes

No

Steroids or cortisone

Yes

No

Are you now taking or using medicines for:

Are you now:

On a prescribed diet

Yes

No

Wearing contact lenses

Yes

No

Do you have any disease, condition, or problem not listed above that you think I should know about? If so, please explain below:

Please check the appropriate box in answer to the following questions.

Do your gums or teeth hurt now?

Yes

No

?

Do your gums bleed?

Yes

No

?

Are you aware of a bad taste or odor in your mouth?

Yes

No

?

Have you had gum boils or abscesses within the past three months?

Yes

No

?

Have you had a toothache within the past three months?

Yes

No

?

Are any of your teeth particularly sensitive to hot or cold?

Yes

No

?

Do you have frequent blisters or canker sores on your lips or mouth?

Yes

No

?

Have you ever had “trenchmouth” or “pyorrhea”?

Yes

No

?

Have you ever had a burning sensation of the tongue?

Yes

No

?

Does your jaw ever get “out of joint”, “click”, or cause pain?

Yes

No

?

Do you clench or grind your teeth?

Yes

No

?

Have you ever had periodontal (gum) treatment?

Yes

No

?

If yes, when?:

Have you ever been treated by a periodontist?

Yes

No

?

If yes, when?:

Have you ever had orthodontic treatment (braces)?

Yes

No

?

If yes, when?:

Are you unusually apprehensive about dental treatment?

Yes

No

?

Do you clean between your teeth?

Yes

No

?

If yes, with what?:

Have you ever been shown how to use dental floss?

Yes

No

?

Have you had any teeth extracted within the past five years?

Yes

No

?

If yes, how many?:

Have you ever been tested for AIDS?

Yes

No

?

How often do you brush your teeth?

What type of tooth brush do you use (hard, medium, soft)?

When were your teeth last “cleaned” by a dentist or dental hygienist?

How frequently have your teeth been “cleaned” by a dentist or a dental hygienist in the last five years?

Patient Statement and Signature:
To the best of my knowledge, the above information I have noted is correct.

Signature

Date

FINANCIAL AGREEMENT

I understand I am financially responsible to Azar & Kepic Periodontics & Dental Implants for all charges for services received and that payment is due in full at the time such services are rendered. All accounts not paid within 30 days of treatment shall be subjected to a late payment fee of 1.5 % per month of the adjusted balance, or 18% annual percentage rate. Such late payment fee shall be waived for any account paid in full within 90 days of treatment. The undersigned agrees, whether he/she signs as agent or as patient, that in consideration of the treatment to be rendered to the patient, he/she hereby individually obligates himself/herself to pay Azar & Kepic Periodontics & Dental Implants in accordance with regular rates and terms of this dental office. Should accounts be referred to an attorney or collection agency for collection, the undersigned shall pay actual attorney’s fees and collection expense.

ASSIGNMENT OF INSURANCE BENEFITS

Insurance is billed as a courtesy to the patient and is not an obligation. Any fees not covered by the insurance plan will be the responsibility of the patient. The undersigned authorizes, whether he/she signs as an agent or as a patient, direct payment to Azar & Kepic Periodontics & Dental Implants of any insurance benefits otherwise payable to or on behalf of the undersigned for treatment rendered. It is agreed that payment to Azar & Kepic Periodontics & Dental Implants, pursuant to this authorization, by any insurance company shall discharge said insurance company of any and all obligations under a policy to extent of such payment. It is understood by the undersigned that he/she is financially responsible for charges not covered by this assignment.

Any condition precedent to recovery or administrative appeals required by the policy shall be the sole responsibility of the patient/guarantor, and not Azar & Kepic Periodontics & Dental Implants. This is requirement shall apply to any and all treatment rendered by Azar & Kepic Periodontics & Dental Implants and his staff.

Signature:

Date:

CONSENT FOR DENTAL TREATMENT ADULT PATIENT

I (print/type name):

herewith grant my permission to Azar & Kepic Periodontics & Dental Implants to perform the following dental procedures:
a complete periodontal examination, periodontal maintenance, administer local anesthetic, do diagnosis or treatment and order x-rays.

Signature:

Date:

CONSENT FOR DENTAL TREATMENT OF A MINOR

I (print/type name):

the parent and/ or legal guardian of (print name):

a minor whose address is:

and DOB is:

herewith grant my permission to Azar & Kepic Periodontics & Dental Implants to perform the following dental procedures:
a complete periodontal examination, periodontal maintenance, administer local anesthetic, do diagnosis or treatment and order x-rays.

Guardian Signature:

Date:

ACKNOWLEDGEMENT OF PRIVACY PRACTICES

My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to:

Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly.
Obtain payment from third party payers and my health care services.
Conduct normal health care operations such as quality assessment and improvement activities.

I have been informed of my dental providers Notice of Privacy Practices containing a more complete description of the uses and disclosure of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain the 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 and I understand that you are not required to agree to my requested restrictions, but if you agree then you are bound to abide to such restrictions.

Patients Name:

Date:

Signature

Relationship to Patient:

For Office Use Only:

We were unable to obtain the patient’s written acknowledgement of our Notice of Privacy Practices due the following reason:

The Patient refused to sign

Yes

Communication barrier

Yes

Emergency situation

Yes

Other

Patient Validation:

Health History Form

PATIENT INFORMATION

HEALTH HISTORY

DENTAL HISTORY

FINANCIAL AGREEMENT

ASSIGNMENT OF INSURANCE BENEFITS

CONSENT FOR DENTAL TREATMENT ADULT PATIENT

CONSENT FOR DENTAL TREATMENT OF A MINOR

ACKNOWLEDGEMENT OF PRIVACY PRACTICES