JOURNAL TRANSCRIPT
Patient Information
Please Print
NAME____________________________________________ __________ Referred to us by__________________________________________ Date of birth_____ _____ _________
Age_____
____Single ____Married ____Divorced ____Widowed ____Separated
____Minor (under 18) ____Full time student Parent/Guardian if minor_____________________________________________________________ Address_________________________________________________________________ Home ph ________ ____________________________ City________________________________________ State_____ Zip_______________ Cell ph ________ ______________________________ ____Male ____Female SS# _________ ________ ___________
Email Address________________________________________
Emergency Contact ____________________________ Relationship ________________________ Emergency ph _______ ___________________ Pharmacy Name ________________________________________ Pharmacy Number____________________________ PERSON RESPONSIBLE FOR PAYMENT______________________________________ Daytime ph ________ _____________________ Address__________________________________________________________________ Driver License State____ #________________ City________________________________________ State_____ Zip_______________ Employed by___________________________________________
Or
Retired from_____________________________________________
Address_______________________________________________
Address________________________________________________
City_________________________ State_____ Zip____________
City_________________________ State_____ Zip_____________
Phone ________ ______________
Phone ________ ______________ Please complete all items below for Dental Insurance processing
DENTAL INSURANCE
____None ___Traditional Dental Insurance ____Dental Plan PPO/DMO
Policy holder______________________________________________________________
Do you need referral from primary dentist? _____
Date of Birth_____ _____ ________
Do you have your dental ID card? _____
___Male ___Female
Address__________________________________________________________________
Are you covered under a 2nd plan? _____
City________________________________________ State_____ Zip_________________ Policy holder SS## ___________ _______ ____________
Patient relationship to policy holder ___Self ___Spouse ___Dependent
Policy holder Ins. ID#_______________________________ Policy holder employer_______________________________________________________ Policy holder employer ph______ ________________ Employer address___________________________________________________________ City________________________________________ State_____ Zip_________________ Insurance company__________________________________________________________ Insurance company ph_______ _________________ Insurance address___________________________________________________________ City________________________________________ State_____ Zip_________________ Group #__________________________ Policy# _________________________________ Release of Information I authorize the release of any information relating to this claim for purposes of insurance. I authorize payment directly Kingwood Dental Specialists of insurance benefits otherwise payable to me. I assume financial responsibility for fees incurred regardless of insurance benefits. Acknowledgement of Receipt of Privacy Statement I acknowledge that I have received or reviewed the Notice of Privacy statement. I agree with the terms and understand my rights under this notice. I consent for the use of my personal health information for treatment, payment, operations and other uses as described in the privacy notice.
______________________________________________________ ______________________ Signature of Patient/Guarantor Date CIRCLE METHOD OF PAYMENT:
CASH
CHECK AMEX
Please present Dental Insurance card to receptionist
VISA
MASTERCARD
DISCOVER 12/16
MEDICAL HISTORY for ENDODONTIC PATIENTS (Root Canal)
ANSWER ALL QUESTIONS. CIRCLE Y (Yes) or N (No)
PRESENT OR PAST CONDITION Congestive heart failure (CHF) …………………… Y Heart disease, arteriosclerosis …………………… Y Angina, chest pain …………………………………. Y Previous heart attack ……………………………… Y Heart surgery ………………………………………. Y Congenital heart defect …………………………… Y Heart valve replacement ………………………….. Y Pacemaker, palpitations ………………………….. Y High blood pressure ……………………………….. Y Low blood pressure ……………………………….. Y Rheumatic fever, rheumatic heart problems …… Y Heart murmur ……………………………………… Y Mitral valve prolapse, other valve problems …… Y Previous stroke, CVA, or TIA ……………………. Y Epilepsy, seizures, convulsions …………………. Y Fainting spells, dizzy spells ………………………. Y Joint, knee, hip replacement ……………………… Y Kidney disease …………………………………….. Y Hepatitis/liver disease Type A B C ……………… Y Thyroid problems, high or low …………………… Y Diabetes in self, mother, father ………………….. Y Anemia, iron deficiency, sickle cell ……………… Y Bleeding disorder, hemophilia, bruising ………… Y Leukemia or other cancer ………………………… Y Chemotherapy, radiation therapy ……………….. Y HIV, AIDS ………………………………………….. Y STD (sexually transmitted disease) …………….. Y Alcohol dependency ………………………………. Y Prescription drug dependency …………………… Y Tuberculosis ……………………………………….. Y Tobacco use of any kind …………………………. Y Asthma, bronchitis, chronic cough ……………… Y COPD, breathing prob, emphysema, pneumonia Y Hay fever, seasonal allergy ………………………. Y Sinus or nasal problems ………………………….. Y Allergies, rash, hives, throat swelling …………… Y Arthritis or inflammatory rheumatism …………… Y Stomach ulcers, colitis, IBS ……………………… Y Mouth ulcers ……………………………………… Y Glaucoma, eye diseases ………………………… Y Jaw surgery ……………………………………….. Y Neuralgia, neuritis in head/neck ………………… Y Osteoporosis, osteopenia ……………………….. Y Depressed immune system …………………….. Y Women: Are you pregnant? Nursing? ………… Y
N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N N
HAVE YOU USED THE FOLLOWING IN PAST 48 HOURS? Cocaine ……………………………………….……. Y N Amphetamines, diet pills ………………………… Y N Ecstasy, Methamphetamines …………………… Y N Herbal remedies or herbal stimulants ………….. Y N Energy boosters containing ephedrine …………. Y N Alcohol, tranquilizers, sedatives …………..……… Y N
ARE YOU NOW UNDER THE CARE OF A PHYSICIAN? Name Specialty Conditions treated
Recent surgery or hospital stay?____________________________ May we request medical information related to your treatment? CURRENT MEDICATIONS YOU’RE TAKING (List below) Antibiotics Y Pain medication Y Oral steroids such as Prednisone Y Aspirin therapy, Aleve, Motrin Y Blood thinners Y Blood pressure meds Y Nitroglycerin Y Digitalis, Inderal Y Cholesterol lowering Y Anti-depressants/tranquilizers Y Insulin, diabetes Y Antihistamines Y Birth control pills Y Asthma meds or inhalers Y Epilepsy/seizure meds Y Thyroid meds Y Fosamax, Actonel, Boniva or other osteoporosis meds … Y Zometa, Reclast, Aredia, Prolia or other IV cancer meds Y Other meds or herbal remedies …………………………..….. Y
HAVE YOU HAD AN ADVERSE REACTION TO: Dental anesthetic (Novocain) ………………………………. Latex or Rubber ……………………………………………… Aspirin or Ibuprophen ………………………………………… Penicillin, Cephalosporin, or other antibiotic ……………… Codeine, Vicodin (Hydrocodone)…………………………… Sedatives, tranquilizers, barbiturates ………………………. Sulfa drugs …………………………………………………… Iodine, metals, chemicals ………………………………….. Foods …………………………………………………………. Other drug reactions
Y Y Y Y Y Y Y Y Y
N N N N N N N N N
DO YOU PREFER NITROUS OXIDE/OXYGEN (laughing gas) FOR TREATMENT? Yes No (There is a fee for this service)
NAME Date of Birth
/
/
Male
Referred By Dr.
Patient Signature (Guardian/parent sign for patient under 18)
Date
OTHER MEDICAL CONDITIONS NOT LISTED ABOVE:
N N N N N N N N N N N N N N N N N N N
For Office Use: Reviewed by Updated by
Date Date
Female
Endodontics Informed Consent for Treatment Woodlands Dental Specialist This is my consent to perform any necessary dental procedures as indicated by my examination which may include, but are not limited to: diagnostic procedures, treatment procedures, use of local anesthetics and sedation with Nitrous Oxide/Oxygen. Every effort has been made to reduce the risks associated with treatment. _____ I understand that although root canal therapy has a high degree of success, it is a biological procedure and has no guarantee of success. Occasionally, a tooth which has been treated by root canal therapy may need re-treatment, surgery, or even extraction. ____ I understand that re-treatment cases or mid-treatment cases (started by another dentist) are more difficult, more prone to complications, and may have a lower success rate. ____ I understand that there are alternatives to root canal therapy or re-treatment root canal therapy which include: no treatment at all, extraction of the tooth with no replacement or replacement with a bridge, partial denture or implant. ____ I understand that the permanent restoration (filling or crown) will be done by my general dentist following root canal treatment. Failure to restore the tooth properly could result in fracturing and loss of the tooth. Follow-up exams and x-rays may be needed to follow the healing of treated teeth. ____ I understand that the injection of local anesthetics may result in soreness, swelling, bruising, and occasionally temporary or permanent numbness of the area injected. For some patients, medications in the injection may cause an increase in heart rate, irregularities in heart rate, or difficulty breathing. ____ I have been informed and understand that there are certain inherent and potential risks in any treatment procedure. These include: Pain, swelling, fever or infection may be present after treatment. Limited jaw opening for treatment may result in short term muscle or jaw pain. Fracture of existing tooth structure, fillings, crowns, or bridges may occur during treatment. Calcified, curved canals may complicate treatment resulting in the root canals being blocked, ledged, or perforated; or the possibility of broken instruments. Slight overfills or underfills of sealer or filling material may occur. Existing multiple pain patterns may require initial treatment plus additional treatment to alleviate pain symptoms. Cracked tooth syndrome: Undetectable by x-ray examination, the majority of cracks occur in the crown portion of the tooth and can be saved with root canal therapy and full crown restoration. Cracks of the root portion of the tooth can affect healing and may result in continued chewing pain and eventual extraction. ____ I understand that I will have an opportunity to ask the endodontist questions and have them answered to my satisfaction prior to treatment. . Signed by Patient, Parent or Agent: __________________________________ Date ____________ Print Name _____________________________________________________
2/10
Woodlands Dental Specialists
Consent for Use and Disclosure of Health Information
Health Insurance Portability and Accountability Act
Please read the following carefully.
Purpose of Consent By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices You have the right to read our Notice of Privacy Practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice is available upon request. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our notice of privacy practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:
1011 Medical Plaza Dr. Suite 210 281.893.1060 Office 281.893.6807 Fax
Consent
I, ______________________________________________________(please print), have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent for your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations.
Signature: X______________________________________________________________ Date: X_______________________ If a personal representative on behalf of the patient is signing this consent, please complete the following:
Personal Representative’s Name: __________________________________________________________________________________________ Relationship to Patient: __________________________________________________________________________________________________
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Right to Revoke You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat or continue treating you if you revoke this Consent.
Revocation of Consent I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations. I understand that revocation of my consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or continue to treat me after I have revoked my consent.
Signature: ____________________________________________________________________ Date: _________________________ If a personal representative on behalf of the patient is signing this revocation of consent, please complete the following:
Personal Representative’s Name: ___________________________________________________________________________________________ Relationship to Patient: ____________________________________________________________________________________________________
Woodlands Dental Specialists ~ Endodontics ~
INSURANCE AGREEMENT We will gladly file a claim for your services on your behalf as a courtesy and accept assignment of benefit (payment to be sent to the practice) from your insurance company to supplement out of pocket expenses. However, it is important to understand insurance is a contract between you, your employer, and the insurance company. We are not a participant in some of these contracts making our practice out of network. Also, it is your responsibility to notify us of any changes or cancellations in your insurance prior to the start of your appointment. We recommend treatment based on individual needs and not insurance benefits. We provide you an estimate of insurance benefits based on the information available. We cannot guarantee the amount your insurance will pay/cover due to many limitations and exclusions in your policy. Any balance not paid by your insurance is still your responsibility. If you do not approve of this policy, we are happy to assist you in filing your own insurance claim.
I understand and acknowledge Woodlands Dental Specialists is out of network with some insurance
companies and cannot guarantee the amount my insurance will pay/cover due to many limitations and exclusions in my policy. PATIENT CANCELLATION POLICY
Please understand that when we schedule your appointment, we are reserving time for your particular needs. We reserve a room for you and your records and insurance is verified and prepared. We kindly ask that if you must change an appointment, please give us at least 24 hours notice. This courtesy makes it possible to give your reserved time to another patient who is in need of it. Please call the office if you need to cancel or reschedule an appointment. We understand that emergencies happen, and will work with any patient that may need to move an appointment. Thank you for your understanding and in order to provide the best experience for all of our patients, we ask that you arrive at your scheduled appointment time.
I understand that there is a $40 charge (per appointment) if I cancel without providing a 24 hours notice
or if I do not show for my appointment. The payment must be made in order to schedule my next appointment. Printed Patient Name(s): ______________________________________________________________ Signature: ____________________________________________________ Date: ________________