MEDICAL UPDATE
PATIENT'S NAME
ADDRESS
CITY
STATE
ZIP
EMAIL
HOME #
CELL #
WORK #
DOB
SEX
Male
Female
ARE YOU A FULL TIME COLLEGE STUDENT? NAME OF SCHOOL AND CITY
Insurance Information
NAME OF INSURANCE
ID #
Group #
SUBSCRIBER'S NAME
SUBSCRIBER'S DOB
INSURANCE PHONE #
EMPLOYERS NAME
DO YOU HAVE OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?
Yes No
Yes No
Yes No
LOW BLOOD SUGAR
CANCER
DIGESTIVE PROBLEMS
DIABETES
LATEX ALLERGY
EATING DISORDERS
HAY FEVER, ALLERGIES
HIV POSITIVE
ARE YOU PREGNANT
ASTHMA
AIDS
RHEUMATIC FEVER
CIRCULATORY PROBLEMS
SPINAL FUSION
MITRAL VALVE PROLAPSE
HEPATITIS A
ARTIFICIAL JOINTS
HEART DISEASE
HEPATITIS B
OSTEOPOROSIS
HEART ATTACK
HEPATITIS C
SINUS PROBLEMS
HEART PACEMAKER
JAUNDICE
ANEMIA
HEART SURGERY
LUNG PROBLEMS
BLOOD DISORDER
STROKE
TUBERCULOSIS
EXCESSIVE BLEEDING
HIGH BLOOD PRESSURE
EPILEPSY / SEIZURE
FAINTING / BLACKOUTS
LOW BLOOD PRESSURE
BLOOD TRANSFUSION
NERVOUS DISORDER
HEART VALVE REPLACEMENT
FACIAL / HEAD INJURY
HEADACHE / MIGRAINES
SEVERE SPINAL STENOSIS
RADIATION
KIDNEY PROBLEMS
THYROID
CHEMOTHERAPY
GLAUCOMA / EYE PROBLEMS
HIGH CHOLESTEROL
MALIGNANCIES
ULCERS
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
ASPIRIN
CODEINE
ANESTHETICS
XYLOCAINE
NOVOCAINE
LIDOCAINE
SEDATIVES
SULFA
PENICILLIN
ERYTHROMYCIN
OTHER:
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?
Yes
No
HAVE YOU NOTICED ANY OF THE FOLLOWING?
Yes No
Yes No
DISCOMFORT IN FACE, HEAD, NECK, JAW
JAW CLICKING OR POPPING
LOOSE TEETH
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
1
Relationship to Patient:
Date
2
Relationship to Patient:
Date
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.
PATIENT NAME
Date
SIGNATURE OF PATIENT OR RESPONSIBLE PARTY:
Please enter code above in the field below.