Patient’s First Name: _________________________________________ Last Name: ________________________________________________ Middle Initial: _____________ Preferred Name: ___________________________________ Home Phone: _____________________ Work Phone: ___________________ Cell Phone: ____________________ Street Address: _____________________________________________________________________________________________________
City: _____________________________________________________ State: _________________ Zip Code: ___________________
Patient’s Sex: Ο Male Ο Female Marital Status: ΟMarried Ο Single Ο Divorced ΟSeparated Ο Widowed
Birth Date: _______________________________ Age: ______ Social Security: ______________________________ Driver License: _____________________________ E-Mail:_____________________________________________________________
Emergency Contact Person: _________________________________________ Emergency Contact Phone: ____________________________________________ Referring Dentist/Physician/Person: __________________________________________________________________________________
Is Patient the ΟInsurancePolicy Holder ΟResponsible Party
Responsible Party (if someone other than the patient)
Patients Relationship to Responsible Party: Ο Self Ο Spouse Ο Child Ο Other
Responsible Party’s First Name: ______________________________________ Last Name: ____________________________________ Middle Initial: _____________ Responsible Party’s Street Address: _____________________________________________________________________________________________________
City: _____________________________________________________ State: _________________ Zip Code: ___________________
ΟResponsible Party is also Policy Holder for Patient Ο Primary InsurancePolicy Holder Ο Secondary Insurance Policy Holder
Primary Insurance Information
Name of Insured: _________________________________________ Patient’s Relationship to Insured: Ο Self Ο Spouse Ο Child Ο Other
Insured Date of Birth: ________________________
Information found on Dental Insurance Card Employer: _________________________________________ Group Number: __________________________ Insured Social Security or Member ID number: ___________________________________ Insurance Company: ____________________________________________ Insurance Company Address: ____________________________________________________________________________________________________________________________ City, State, and Zip Code: __________________________________________________________________________________________________________________________________
Secondary Insurance Information
Name of Insured: _________________________________________ Patient’s Relationship to Insured: Ο Self Ο Spouse Ο Child Ο Other
Insured Date of Birth: ________________________
Information found on Dental Insurance Card Employer:_______________________________________ Group Number: __________________________ Insured Social Security or Member ID number: ___________________________________ Insurance Company: ____________________________________________ Insurance Company Address: ____________________________________________________________________________________________________________________________ City, State, and Zip Code: __________________________________________________________________________________________________________________________________
MEDICAL HISTORY
PATIENT NAME _____________________________________________________ Birth Date___________________________________
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician's care now? Yes No If yes, please explain: ____________________________________ Have you ever been hospitalized or had a major operation? Yes No If yes, please explain: ____________________________________ Have you ever had a serious head or neck injury? Yes No If yes, please explain: ____________________________________ Are you taking any medications, pills, or drugs? Yes No If yes, please explain: ____________________________________ ____________________________________________________________________________________________________________________ Do you take, or have you ever taken, Phen-Fen or Redux? Yes No
Are you on a special diet? Yes No If yes, for what reason:____________________________________ Do you use tobacco? Yes No If yes, how much:________________________________________ Do you use controlled substances? Yes No If yes, what do you use:___________________________________ Women: Are you Pregnant/Trying to get pregnant? Yes No Taking oral contraceptives? Yes No Nursing? Yes No Are you allergic to any of the following?
Aspirin Penicillin Codeine Acrylic Metal Latex Local Anesthetics Other
If other, please explain:________________________________________________________________________ Do you have, or have you had, any of the following?
AIDS/HIV Positive Yes No Cortisone Medicine Yes No Hemophilia Yes No Renal Dialysis Yes No Alzheimer's Disease Yes No Diabetes Yes No Hepatitis A Yes No Rheumatic Fever Yes No Anaphylaxis Yes No Drug Addiction Yes No Hepatitis B or C Yes No Rheumatism Yes No
Anemia Yes No Easily Winded Yes No Herpes Yes No Scarlet Fever Yes No
Angina Yes No Emphysema Yes No High Blood Pressure Yes No Shingles Yes No Arthritis/Gout Yes No Epilepsy or Seizures Yes No Hives or Rash Yes No Sickle Cell Disease Yes No Artificial Heart Valve Yes No Excessive Bleeding Yes No Hypoglycemia Yes No Sinus Trouble Yes No Artificial Joint Yes No Excessive Thirst Yes No Irregular Heartbeat Yes No Spina Bifida Yes No Asthma Yes No Fainting Spells/Dizziness Yes No Kidney Problems Yes No Stomach/Intestinal Disease Yes No Blood Disease Yes No Frequent Cough Yes No Leukemia Yes No Stroke Yes No Blood Transfusion Yes No Frequent Diarrhea Yes No Liver Disease Yes No Swelling of Limbs Yes No Breathing Problem Yes No Frequent Headaches Yes No Low Blood Pressure Yes No Thyroid Disease Yes No Bruise Easily Yes No Genital Herpes Yes No Lung Disease Yes No Tonsillitis Yes No Cancer Yes No Glaucoma Yes No Mitral Valve Prolapse Yes No Tuberculosis Yes No Chemotherapy Yes No Hay Fever Yes No Pain in Jaw Joints Yes No Tumors or Growths Yes No Chest Pains Yes No Heart Attack/Failure Yes No Parathyroid Disease Yes No Ulcers Yes No Cold Sores/Fever Blisters Yes No Heart Murmur Yes No Psychiatric Care Yes No Venereal Disease Yes No Congenital Heart Disorder Yes No Heart Pace Maker Yes No Radiation Treatments Yes No Yellow Jaundice Yes No Convulsions Yes No Heart Trouble/Disease Yes No Recent Weight Loss Yes No
Have you ever had any serious illness not listed above? Yes No If yes, please explain:______________________________________
_________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ Comments: _______________________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
Northwest Periodontics
Stanley D. Halpern, D.D.S., P.C.
Practice Limited to Periodontics & Implants
220 Heritage Walk, Suite 102
Woodstock, Georgia 30188
Office 770-928-6655
Fax 770-928-6656
Dental Health Information
Reason for your visit to our office:_______________________________________________
Date of last dental visit:____/___/___ Date of last dental cleaning:___/___/___
Yes
No
Are you in pain? ... ____ ____
Are you under unusual stress at home/work? ... ____ ____
Have you had temporomandibular joint (TMJ) problems before? ……… ____ ____
Do you clench or grind your teeth? ... ____ ____
Do your gums feel tender or swollen? ……….. ____ ____
Do your gums bleed while brushing or flossing? (circle one or both) ……… ____ ____
Do you gag easily? ……… ____ ____
Do you have an electric tooth brush?... ____ ____
If yes, what name brand? __________________________
Have you ever been given Nitrous Oxide (laughing gas)? ____ ____
Do you like Nitrous Oxide? ____ ____
Are our teeth sensitive to: (Circle all that apply) Cold Hot Sweet Sour
Do you wear dentures upper/lower or partials upper/lower? (circle all that apply)
How often do you brush your teeth? ____________________________
How often do you floss your teeth? _____________________________
What type of toothpaste do you use? ____________________________
Texture of toothbrush you use? _______________________________
Practice Limited to Periodontics and Implants
220 Heritage Walk
Suite 102
Woodstock, Ga. 30188
Office:(770) 928-6655
Fax:(770) 928-6656 ACKNOWLEDGEMENT OF RECEIPT OFNOTICE OF PRIVACY PRACTICES
**You May Refuse to Sign This Acknowledgement**
Date: _____________________________ I, (Please Print Name) ________________________________ have received a copy of this office’s Notice of Privacy Practices.
I authorize the release of medical/dental information. Including but not limited to diagnosis, records, examination, or treatment rendered to me and/or claims/account information. This information may be released to:
Please check and give name of all that apply
[ ] Spouse:_________________________________ [ ]Parent:________________________________________ [ ]Child:___________________________________ [ ]Other:_________________________________________ [ ] Or you prefer your information not to be released to anyone.
This release of medical/dental information will remain in effect until terminated by me in writing. Messages/Appointment Reminders
Please call: [ ] Home:_____________________________ [ ]Cell:_______________________________________ [ ] Work:___________________________ Ext:____________________
If unable to reach me:
[ ] You may leave a detailed message
[ ] Please leave a message asking me to return call [ ] Or ________________________________________________
The best time to reach me is (day & time) __________________________________________
Signature of Patient/Patients Responsible Party:______________________________________________________ For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained due to:
o Individual refused to sign
o Communications barrier prohibited obtaining the acknowledgement
Practice Limited to Periodontics and Implants 220 Heritage Walk Suite 102 Woodstock, Ga. 30188 Office:(770) 928-6655 Fax:(770) 928-6656
Office Policies
We are committed to providing you with the best possible care. We emphasize our team’s relationship with you and your optimal dental health. We are pleased to discuss our professional fees with you at this time. Your clear understanding of our Financial Policy is important to our professional relationship. Please ask if you have any questions about our fees, financial policy, or your responsibility.
- All patients must complete our “PATIENT INFORMATION FORM” before seeing the doctor.
- All applicable co-pays, personal balances, both current and prior are due at the time of service.
- WE ACCEPT CASH, CHECKS, DISCOVER, VISA/MASTERCARD and AMERICAN EXPRESS
Please circle your payment choice for today’s visit. REGARDING INSURANCE:
If you have insurance, we are happy to file your insurance claim as a courtesy. We will submit your insurance to reimburse you for your first visit. We will accept insurance assignment if we have a written pre-determination from your insurance company and will require you to pay the difference at the time of service. If you choose to have treatment done before a pre-determination has been received back from insurance, you will be responsible for 50% of the balance before treatment. Late Payment Charges are added to unpaid accounts after 60 days from date of service. If your insurance company pays more than the balance due, we will send a refund check to you in a timely manner.
INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. Not every dental service is a “covered” benefit in all insurance policies. Policy limitations vary from contract to contract. Failure to provide updated insurance information may result in denials, which the patient will be held responsible.
MISSED APPOINTMENTS:
Unless cancelled at least 48 hours in advance, it is our policy to charge $75.00 or 15% of the scheduled appointment fee, whichever is greater. This fee is not covered by insurance. After the first broken appointment, Northwest Periodontics reserves the right to require a deposit for any future appointments payable at the time of scheduling. This deposit is non-refundable if you cancel appointment with less than 48 notice. It will go toward co-pay when you keep your appointment.
LATE ARRIVALS:
Patients who are 15 minutes late to their appointments will be asked to reschedule, or if the doctor’s time allows will be worked in around our other patients. The Atlanta Area is very congested with traffic and construction, so please allow extra travel time.
YOUR SIGNATURE IS REQUIRED FOR US TO:
PROCESS ALL INSURANCE CLAIMS
TO ENSURE PAYMENT FOR SERVICES RENDERED
TO RELEASE MEDICAL INFORMATION TO INSURANCE COMPANIES
TO RELEASE INFORMATION TO OTHER MEDICAL/DENTAL PROVIDERS, WHEN NECESSARY,
FOR YOUR TREATMENT.
TO RECEIVE INFORMATION FROM OTHER PROVIDERS AND INSURANCE COMPANYS TO
FACILITATE YOUR TREATMENT
I authorize the release of all medical information necessary to process my claims and I authorize the release of this same information, when necessary, to other providers rendering medical/dental care. I assign all medical surgical benefits, including major medical to which I am entitled, to Stanley D. Halpern, D.D.S., P.C. This assignment will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.
Patients Name: __________________________________ Today’s Date:_____________________ (Please Print)
Responsible Party’s Name: ___________________________ (Please Print)
Responsible Party’s Signature: _________________________ Witness Signature: _____________________________