Patient Information Appointment Personal details Medical history HIPPA form & Release of information Financial and cancellation policy Personal Details GenderMaleFemale Date of birth Address Details Next Medical history Although Dental personnel treat the area in and around your mouth, you mouth is a part of your entire body. Please inform us of any health problems you may have or medication you are taking. Are you under the care of a physician right now? YesNo If yes Have you ever been hospitalized or had a major operation? YesNo If yes Have you ever had a serious head or neck injury? YesNo If yes Are you taking any medications, pills, or drugs? YesNo If yes Do you take, or have you taken, Phen-Fen or Redux? YesNo If yes Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? YesNo If yes Are you on a special diet? YesNo Do you use tobacco? YesNo Women: Are you……. Pregnant/Trying to get pregnantNursing?Taking Oral contraceptives? Are you allergic to any of the following? AspirinPenicillianCodeineAcrylicMetalLatexSulfa DrugsLocal Anesthetics Other? YesNo If yes Do you use Controlled Substances YesNo If yes Do you or have you had any of the following conditions? AIDS/HIV YesNo Cortisone Medicine YesNo Hemophilia YesNo Radiation Treatment YesNo Alzheimer’s YesNo Diabetes YesNo Hepatitis A YesNo Recent Weight Loss YesNo Anaphylaxis YesNo Drug Addiction YesNo Hepatitis B or C YesNo Renal Dyalysis YesNo Anemia YesNo Easily Winded YesNo Herpes YesNo Rheumatic Fever YesNo Angina YesNo Emphysema YesNo High Blood Pressure YesNo Rheumatism YesNo Arthritis/Gout YesNo Epilepsy or Seizures YesNo High Cholesterol YesNo Scarlet Fever YesNo Artificial Heart Valve YesNo Excessive Bleeding YesNo Hives or Rash YesNo Artificial Joint YesNo Excessive Thirst YesNo Hypoglycemia YesNo Sickle Cell Disease YesNo Asthma YesNo Fainting Spells/Dizziness YesNo Irregular Heartbeat YesNo Blood Disease YesNo Frequent Cough YesNo Kidney Problems YesNo Spina Bifida YesNo Blood Transfusion YesNo Frequent Diarrhea YesNo Leukemia YesNo Stomach/Intestinal Disease YesNo Breathing Problems YesNo Frequent Headaches YesNo Liver Disease YesNo Stroke YesNo Bruise Easily YesNo Genital Herpes YesNo Low Blood Pressure YesNo Swelling of Limbs YesNo Cancer YesNo Lung Disease YesNo Thyroid Disease YesNo Chemotherapy YesNo Hay Fever YesNo Mitral Valve Prolapse YesNo Tonsillitis YesNo Chest Pains YesNo Heart Attack/Failure YesNo Osteoporosis YesNo Tuberculosis YesNo Cold Sores/Fever Blister YesNo Heart Murmur YesNo Pain in Jaw Joints YesNo Tumors/Growths YesNo Congenital heart Disorder YesNo Heart Pacemaker YesNo Parathyroid Disease YesNo Ulcers YesNo Convulsions YesNo Heart Trouble/Disease YesNo Psychiatric Care YesNo Venereal Disease YesNo Yellow Jaundice YesNo Have you ever had any serious illness not listed? YesNo Comment PreviousNext HIPPA form & Release of information I_________have Received a copy of this offices notice of privacy policy. We attempted to obtain written acknowlegement of reciept of notice of privacy practices but:* Refused To SignCommunications Barrier Probhibits AcknowlegementAn Emergency Situation Prevented From Obtaining AcknowlegementOther(Specify) Please Give Emergency Phone Number* Person Who can access your Dental Records I agree to the HIPPA form terms and conditions. I agree to the Release of Information terms and condtions. PreviousNext Financial and cancellation policy Corwin Family Dentistry Cancellations and Failed Appointments We are committed to providing the best dental care to our patients and to keeping your costs as low as possible. In order to accomplish this, it is imperative that appointments that are made with us are kept. If you are unable to keep an appointment, we require 24hours notice, so that other patients who need to be seen can be scheduled. If an appointment is missed without any notice, or for excessively canceling appointments with less than 24hours notice, there will be a $100 charge and a current credit card will be required to be on file. If a second appointment is missed or cancelled, the full fee for the appointment will be charged to your card. Financial Policy Each patient will be given a treatment plan for any appointment that is planned. The treatment plan details the cost of our services and an estimate of how much insurance will contribute. If you have any questions about the cost of your treatment, please ask before scheduling your appointment. Payment in full for work done is required at the time or the appointment, either by cash, check or credit card. If your insurance has not paid on a claim within 60 days, you will be responsible for the unpaid portion and we will send a bill for that amount. If the payment from insurance comes to us after you’ve paid it, we will send you a reimbursement check. Your Insurance We are happy to help answer general questions about dental insurance. However, we must stress that your policy is an agreement between you and your insurance company, and that we are a third party to that contract. If you have specific questions about your policy, you can call your insurance company: They will be able to give you more specific information. If you have questions about any of these policies, please ask for clarification prior to your appointment. How would you like your appointments confirmed:* E-MailTextPhone call I agree to the terms and conditions. Previous
