PATIENT INFORMATION
Patient's name __________________________________________________________________________________
Preferred name ________________________________________ ☐ Male ☐ Female
If minor, responsible party name ___________________________________________________________________
Mailing address ______________________________ City ________________ State ______________ Zip ________
Social Security Number ____________________________ Birth date______________________________________
Home phone _____________________________________ Work phone ____________________________________
Cell phone _______________________________________ Email _________________________________________
Employer ___________________________________ Occupation _________________________________________
Marital Status ☐ Single ☐ Married ☐ Divorced ☐ Widowed ☐ Separated ☐ Domestic Partner
Spouse's name ____________________ Spouse's employer _____________________________________________
How did you hear about our office? _______________________________________________________
BILLING, CREDIT, AND BILLING INFORMATION (Please fill out completely)
Subscriber Name ___________________ Relationship to Patient__________ Subscriber DOB _________________
SSN/ID ____________________________ Subscriber Employer __________________________________________
Insurance Company Name ______________________ Group Number _____________________________________
SECONDARY INSURANCE (If applicable)
Subscriber Name ___________________ Relationship to Patient__________ Subscriber DOB _________________
SSN/ID ___________________________ Subscriber Employer ___________________________________________
Insurance Company Name ______________________ Group Number _____________________________________
RELEASE
I authorize Dr. Worrell to perform diagnostic procedures and treatment as may be necessary for proper dental care.
I authorize release of any information concerning my (or my child’s) health care, advice and treatment provided for the purpose of evaluating and administering claims for insurance benefits.
I authorize release of any information concerning my (or my child’s) health care, advice and treatment to another dentist.
I hereby authorize payment of insurance benefits directly to the dentist or dental group, otherwise payable to me.
I understand that my dental care insurance carrier or payor of my dental benefits may pay less than the actual bill for services. By signing this statement, I revoke all previous agreements to the contrary and agree to be responsible for payment of services not paid, in whole or in part by my dental or medical care payor.
I understand that I am financially responsible for payment in full of all accounts. Finance charges of 1% monthly will be applied to balances due over 90 days (per RCW 19.52)
SIGNATURE OF PATIENT/GUARDIAN ____________________________________ DATE _________________________
MEDICAL HEALTH HISTORY
Patient’s Name ________________________________ DOB _______________
Are you under a physician’s care now? ☐ Yes ☐ No If Yes_______________________________
Have you ever been hospitalized or had a major operation? ☐ Yes ☐ No If Yes_______________________________
Have you ever had a serious head or neck injury? ☐ Yes ☐ No If Yes_______________________________
Are you taking any medications, pills, or drugs? ☐ Yes ☐ No If Yes_______________________________
Do you take, or have taken, Phen-Fen or Redux? ☐ Yes ☐ No If Yes_______________________________
Have you ever taken Fosamax, Boniva, Actonel or any ☐ Yes ☐ No If Yes_______________________________
Other medications containing bisphosphonates? ☐ Yes ☐ No If Yes_______________________________
Do you use tobacco? ☐ Yes ☐ No Women: Are you…
☐ Pregnant/Trying to get pregnant? ☐ Nursing ☐ Taking oral contraceptives Are you allergic to any of the following?
☐ Asprin ☐ Penicillin ☐ Codeine ☐ Acrylic
☐ Metal ☐ Latex ☐ Sulfa Drugs ☐ Local Anesthetics
Other? _____________________________________________________
Do you use controlled substances? ☐ Yes ☐ No If yes _______________________________
Do you have or have you had any of the following? (PLEASE CHECK ANY THAT APPLY)
AIDS/HIV Positive
Alzheimer’s Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problems
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Nearest Relative not living with you:
Name _____________________________ Relationship ________________________ Phone ______________________
Do you have any disease, condition, or problem not listed above? __________________________________________
Signature of patient (or parent) _______________________________________ Date ________________
Diabetes
Drug Addiction
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Headaches
Glaucoma
Hay fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Hemophilia
Hepatitis
High Blood Pressure
High Cholesterol
Hypoglycemia
Kidney Problems
Liver Disease
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Stomach/Intestinal Disease
Stroke
Thyroid Problems
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
DENTAL HISTORY
How may we help you today? ____________________________________________________
Your current dental health is: ☐ Good ☐ Fair ☐ Poor
Do you require antibiotics before dental treatment? ☐ Yes ☐ No
Are you currently in pain? ☐ Yes ☐ No
Have you ever had gum treatment? ☐ Yes ☐ No
Do you now or have you had any pain/discomfort in your jaw joint? (TMJ) ☐ Yes ☐ No Are you under stress? (New Job, Moving, Relationships) ☐ Yes ☐ No
Do you like your smile? ☐ Yes ☐ No
Is there anything you would like to change about your smile? ☐ Yes ☐ No Are you happy with the color of your teeth? ☐ Yes ☐ No
Do your gums bleed? ☐ Yes ☐ No
How many times do you: Floss/week? _______________ Brush/day? ___________________
Are your teeth sensitive to heat, cold or anything else? ☐ Yes ☐ No
Have you lost any teeth? ☐ Yes ☐ No
Have you ever had any unfavorable dental experiences? ☐ Yes ☐ No When was your last dental cleaning? ______________________________________________
When was your last dental visit? __________________________________________________
Why did you leave your previous dentist? __________________________________________
How can we accommodate you better during your dental visit? ________________________
Here at WEDental, we offer a wide variety of services to enhance and keep your smile beautiful. Please circle any services below you would like our friendly staff to discuss with you during your visit.
Teeth Whitening
Traditional Orthodontics Invisalign
Partials/Dentures Veneers/Lumineers Smile Makeover Sealants
Bonding Crowns
Night/Sport Guards
FINANCIAL POLICY
In the interest of good communication and our continued commitment to provide the highest quality of dental care available to all of our patients, we have established a Patient Financial Policy. It is our hope that this policy will facilitate open communication between us and help avoid potential misunderstandings, allowing you to always make the best choices related to your care.
We are committed to support you in understanding your dental health, and will always present you with the best dental solution possible to treat your personal situation. To make these services comfortably affordable we are pleased to offer you the following payment options.
Cash, Check
Visa, MasterCard, Discover, AMEX
CareCredit (Financing)
We will, as a courtesy, process your insurance benefits in our office. All questions regarding your insurance benefits must be addressed to your insurance carrier.
I agree that I am fully responsible for the total payment of all procedures performed in this office – this includes any treatment that is not a benefit of any dental insurance that I may have. I understand that any estimated portion, not covered by insurance, is due at time of service for all services rendered. I understand that all services are due to be paid within ninety (90) days of date of service, regardless of whether or not my insurance benefits have been received. One percent (1%) per month interest, twelve percent (12%) per year will be charged on accounts 90 days from treatment date (per RCW 19.52). I also understand that should credit be extended to me by this dental office, a credit check will be made through WEDental or other credit services and I authorize release of all financial data.
Please make your questions and concerns known to our Accounts Manager who is happy to discuss this policy and ensure that you have an outstanding experience.
________________________________________________ _____________________
Signature of Patient/Guardian Date
CANCELLATION, MISSED APPOINTMENT POLICY
Our office is designed to give each individual our personalized care, as a courtesy we do ask that if you need to change an appointment time that you give us 48 hours advanced notice so that we may give that time to someone else in need.
An appointment is considered broken for one or more of the following reasons:
1. Failure to show up for a scheduled appointment
2. Canceling an appointment without giving 48 hour notice 3. Showing up more than 15 minutes late for an appointment.
The broken appointment fee is $50.00 per patient, as it is difficult to fill our schedule on a last minute basis.
By signing the agreement I understand the policy as defined above and agree to abide by it.
________________________________________________ _____________________
Signature of Patient/Guardian Date
ACKNOWLEDGEMENT OF STATEMENT OF PRIVACY PRACTICES
I acknowledge that I have received a copy of the Statement of Privacy Practices for the office of WEDental. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.
WEDental reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.
ADDITIONAL DISCLOSURE AUTHORITY
In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below. (I understand that the default answer is “NO”. Without indicating “YES” in answer to the each individual question, personal protected (PHI) cannot be shared with anyone unless otherwise allowed by HIPPA rules)
ANY MEMBER OF MY IMMEDIATE FAMILY YES NO
SPOUSE ONLY YES NO
OTHER (PLEASE SPECIFY): _______________________ YES NO
_________________________________________ ___________________________________________________
Printed name of Patient or Personal Representative Signature of Patient or Personal Representative
_________________________________________ ____________________________________________________
Date Description of Personal Representative’s Authority
OFFICE USE ONLY BELOW THIS LINE
RECORD OF ACKNOWLEDGEMENT NOT OBTAINED
PROVIDED PRIOR TO TREATMENT? YES NO
DATE PROVIDED:
REASON FOR DENIAL: NEEDED MORE TIME TO REVIEW STATEMENT OF PRIVACY PRACTICES?
WANTED TO CONSULT WITH ANOTHER PERSON, BEFORE SIGNING.
UNABLE TO SIGN.
REASON NOT GIVEN.
OTHER (EXPLAIN): ____________________________________________
