ARE YOU A FULL TIME COLLEGE STUDENT? NAME OF SCHOOL AND CITY
NAME OF INSURANCE
INSURANCE PHONE #
DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?
LOW BLOOD SUGAR
HAY FEVER, ALLERGIES
ARE YOU PREGNANT
MITRAL VALVE PROLAPSE
HIGH BLOOD PRESSURE
EPILEPSY / SEIZURE
FAINTING / BLACKOUTS
LOW BLOOD PRESSURE
HEART VALVE REPLACEMENT
FACIAL / HEAD INJURY
HEADACHE / MIGRAINES
SEVERE SPINAL STENOSIS
GLAUCOMA / EYE PROBLEMS
DO YOU HAVE ANY OTHER DISEASES OR CONDITIONS NOT LISTED ABOVE? IF YES PLEASE LIST:
DO YOU HAVE ALLERGIES TO ANY OF THE FOLLOWING? PLEASE CHECK ALL THAT APPLY
LIST ALL MEDICATIONS CURRENTLY BEING TAKEN OR A PRINTED COPY OF YOUR LIST:
NAME OF PHYSICIAN:
PHONE OF PHYSICIAN:
HAVE YOU BEEN HOSPITALIZED IN THE LAST YEAR? IF YES, PLEASE EXPLAIN
DATE OF YOUR LAST DENTAL CLEANING
WAS YOUR LAST DENTAL CLEANING AT THIS OFFICE?
HAVE YOU NOTICED ANY OF THE FOLLOWING?
DISCOMFORT IN FACE, HEAD, NECK, JAW
JAW CLICKING OR POPPING
SWELLING OR LUMPS IN MOUTH
FOOD CAUGHT BETWEEN TEETH
BLEEDING OR SORE GUMS
SENSITIVITY TO SWEETS, HOT OR COLD
RECURRING SORE IN OR AROUND MOUTH
TEETH TENDER TO CHEWING
To avoid any misunderstanding concerning your dental insurance, we wish for our patients to know that all professional services rendered will be out of network andcharged directly to the patient who is responsible for the payment of said services. We do not render service or treatment on the basis that the insurance company will pay our fees unless a pre-determination of benefits has been established in writing. However, we will file the necessary insurance forms for all treatment and services that have been completed. Payment is due when the service is rendered unless other arrangements have been made. If you must change a scheduled appointment, please inform the office within 24 hours of your scheduled appointment to avoid a charge to your account.
I hereby authorize Chase Hall, DMD to take radiographic X-rays, study models, photographs or any other diagnostic aid deemed necessary to make a thorough diagnosis for my dental care. I also authorize the doctor to prescribe necessary forms of medication, and to perform any treatment that may be indicated and agreed upon regarding my dental care.
I understand my rights to privacy regarding my protected health information under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that this information can and will be used to provide and coordinate my treatment among consulting health/dental care providers who may be involved in that treatment directly and indirectly. I further authorize the release of any information regarding the diagnosis and records of treatment to my insurance company. The release of such information to the insurance company is solely for the purpose of facilitating the billing and reimbursement of treatment directly to the dentist for insurance benefits under which I am entitled. I understand the responsibility for payment of services rendered for myself and my family are due and payable at the time the services are performed.
Under the requirements for HIPAA we are not allowed to give your protected health information to anyone without your consent. If you wish to have a family member or someone close to you have access to your private health information, please indicate below.
You May Disclose My Information To The Following
Do Not Disclose My Information To Anyone But Me
Relationship to Patient:
Relationship to Patient:
MY SIGNATURE CONFIRMS THAT I UNDERSTAND ALL HIPAA AND FINANCIAL POLICIES AS OUTLINED ABOVE AND THAT THE HEALTH AND DENTAL INFORMATION THAT I HAVE PROVIDED IS CORRECT TO THE BEST OF MY KNOWLEDGE.
SIGNATURE OF PATIENT OR RESPONSIBLE PARTY:
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