2 (PLEASE PRINT) we Date SSIHICIPetient 10 # Patient Name Ineurance Co, Tae Group # FN 's patient covered by adktional insurance? C)Y¥es C)No: Adress — Subscribers Nam. emai ~ Birthdate___........__ 884, ~ ony, Relationship to Patent Siete ip Insurance Co, —__ Sec OM OF Age Group # __ _ Birthdate, —_ ASSIGNMENT AND RELEASE nnn: Gre ceily that 1 andlor my dependants), have insuranca coverage with separated = C1 Divorced (Ci Partnered for__ years. Nae of insiran — ondassion seco Patient EmployerSchool o_o sant, Occupation thanlytoponatie rl charge eter rh pai by res. | uhose the ube of my sgnatia onal insuranco submission EmployenSchool Address ‘The above-named dentist may ueo ry healthcare inormaton ard may diclose uch mfermaton tthe above-named Insurance Cernpanies) an thi agen ft the purpoes of ebsning paymon or sevens and demining insurance bones ) — trihe Benes payee roles sores, This consent wil end when my creat {teatment plan le completed or one year fom fe date eigned elon, Employer/School Phone (_ ‘Spouse's Name Birthdate, Sigraurs of Pant, Parent, Guar or PoreonalRepresoriatve ssF Fase pat name af Paver, Parsi ian or Paral Representative Spouse's Employer Whom may wo thank for referring Home ( Work tt Phone (_) Spouse'sWork {__}____————Best te and pace to reach you INCASE OF EMERGENCY, CONTAGT (Speci someone who doesnot vein your household) Name : Retaionship, Phone (__). __ At Phone (_) __ (Qe Reason or todays vsit_____———————Buring sensation onengueC]Yee Ne Mouth beating vee Ne Chew on ene sie of mouth Yes CIND Mouth pan busing Cig, pipe, or ner smoking CIYes Ne Ochedonte raiment Former Dentist_______________Giicking or popping jaw (Yes [)No Pain around ear No. Ciyistate youth Yes DINo Periodontal treatment Des One cae ohealoonarwen goal bing IVes No Senstivty to cols Yes Ne ‘ate of last cenval Vis —— Food collection between the teeth [Yes [INo Sensitivity to heat Dyes O1No Dato of last dental xrays. - Foreign objacts [Yee EINo Sensitity to swoots (ves GNo Place a mark on yes" or ‘no"toinccate # you Grinding teeth [Yes [No Sensitvty when bing ves CINo have had any of the following: Gums swollen or tender Tes [No Sores or growths in your mouth [Yes []No Bad breath [Yee C1Ne Jew pain or rocness Y** CN fey oten do you as? Bleeding guns Caves Ne Up orcheek bing Gives Ne Bisterson ips ormouth __ClYes CINo Loose txt orboken fogs ClYes_C]No How often do you bran? - Dental Registration and History ev aen12 OVER hese As Pass -005262170| C)) Healthy History Physicln’s Name ——____ Date of tastvik___ Have you ever used a bisphosphonate medieation? Common brand names are Fosamax, Actonel, Atelvia, Didronel, Boniva. Cl¥es LINO Have you ever takon any ofthe group of druge collectively reterted to ae “Yen-phien?" Those include combinations of lonimin, Adipex, Fastin (brand ‘names of phentermine), Pondimin (fenfluramine) and Redux (dextenfiuramine).(1Yes [No Place a mark on "yes" or "no to indicate if you have had any of the following: AIDSIMIV Yes CINo Epilepsy (Yes CINo Respiratory Disease (Yes C1No ‘Anemia yes CNo Fainting or dizziness [Yes CINo Rheumatic Fever (Yes CINo Artis, Bhaumatm Tes CN Glaucoma Yes (No Scarlet Fever (Yes CINo Aviclal Heart Vatves ves CNo Headaches 5 No Shortness of Breath Cives Acti Joints (Yes CNo Heart Murmur (Yes CNo Sinus Trouble ves Asthma Yes CN Heart Problems (es CINo skin Rash ves Back Problems ves CINo Hepatitis Type — Yes TINo Special Diet Bleeding abnormally, with Herpes [ves TINe Stroke entactions or surgery Cl¥es CINo High Blood Pressure [Ys CINo Swollen Fest or Ankles Dyes Blood Disease ves No Jaundice Yes No Swollen Neck Glands Dyes Cancer Ces CINo Jaw Pain [Yes CINo Thyroid Problems Des Chemical Dependency Cl¥es No Kidney Disoaso (Yee CNe Tonsil Dyes DNo Chemotherapy ClYes CNo Liver Disease Yes CINe Tuberculosis [yes No Circulatory Problems ClYes CNo Low Blood Pressure [Yes ENe Tumor or growth on head Congenital Heart Lesions «Yes No Mitral Valve Protapso Tves Ne orneck Des CNo Cortsone Treatments Dies No Nervous Problems ves Ne Ulcer Cough, persistent or bloody Yes (No Pacemaker [ves CN Venere! Disease Dyes CNo Diabetes Ti¥es No Psychiatic Care [ves FNo Weight Loss, unexplained Eves. No Emphysema [Yes [No Radiation Treatment ves Ne Do you wear contact lenses? Yes LINo Wome ‘Are you pregnant? C1Yes_ CINo ve date__ ‘Are you nursing? ClYes No ‘Taking birth contol pile? C1Yes C1 No Drinenen Cerio List any medications you are curently taking and the correlating aspirin Local Anesthetic diagnosis: [i Barbiturates (Steeping pile) Dicodsine PharmacyNeme Dieaine 7 Phone ( es Dhatex (ETE ein ments) Has there been any change in your heath since your last dental appointment? []Yes [No For what conditions? ‘Are you taking any new medications? M60, what? _ = Patient's Signature Date Doctors Signature - — Date__ —_ Has there been any change in your heath since your last dental appointment? C]Yes No For what eonsitions? ‘Are you taking any new medications? Vso, what? Patient's Signature Doctor's Signature -Welcome to Delaware Maryland Dental! Please take the time and read our office policies below. If you have any questions, please ask our knowledgeable front staff prior to signing. * We do require payment at the time of service. If you are unable to pay for your visit, please let us know prior to any work. For any major work, (Bridges, Partials, Dentures) we will need to collect prior to the delivery. ‘+ We accept the following forms of payment: cash, check, Visa, Mastercard, Discover,and Care Credit. We do not except American Express. There would be a $35.00 service fee for any returned checl ‘* We proudly accept most insurance companies. We do collect all co-pays/coinsurances at the time of service by your insurance guidelines given to us. Unfortunately, there are times the insurance company may change coding and make your responsibility higher. This balance should be paid on or before your next appointment. **our office only does the composite fillings (tooth colored). This may add additional charges as some insurance companies do not allow these. + Tobe able to give excellent patient care we ask for patients to be on time; however if an emergency does arise we will allow a 10 minute window for tardiness. After this time frame we would need to reschedule your appointment. © We require 24 hours notice to reschedule or cancel an appointment. For appointments not cancelled or rescheduled within 24 hours there is a $25.00 fee /half hour appointment was scheduled for. * Please do not eat or drink in the office. © We require any minors (under 18 years old) to have a parent or guardian (if guardian we need letter from parent) present in the office at all times. © Torelease your records we require a signed release. We require 7-10 business days to complete the duplication process. Our x-rays are now digital and would need to be e-mailed. ‘© Please notify staff of any personal or insurance information changes. Print and Sign Date Patient Name: Date of Birth: Relationship to Patient:Dental Treatment and Consent: lunderstand that | may have cleanings, fillings, bridges, extractions, root canals, crowns, dentures or partials, and local anesthesia. With any and all dental procedures there are risks; such as numbness, swelling, bruising, cuts, abrasions, and tenderness. | understand it may be necessary to change or add procedures because of conditions found while working on my teeth. understand that antibiotics, analgesics, and other medications may cause allergic reactions such as but limited to, nausea, vomiting, redness, swelling, itching, and in severe cases anaphylactic shock. T understand it is of utmost importance to inform Delaware Maryland Dental of any changes to my medical history which includes diagnosis and medications. There are some surgeries and medications that are contraindicated with certain dental procedures and can affect dental treatment. If you have any questions, please ask our staff prior to signing. Print and Sign Date Patient Name: Date of Birth Relationship to patient:Authorization to Release Informa (If you wish us to be able to talk/discuss your information with your ‘spouse or parents we MUST have their names filled in below) Purpos his form is used to obtain authorization to release your personal health information to another person other than yourself under the Privacy Act. authorize the following person(s) to have access to information covered under the Privacy Practice regarding myself. 2). 2), Please Print Name Relationship Please Print Name Relationship 3). 4) Please Print Name Relationship Please Print Name Relationship Print and Sign Date Relationship to patient DateAcknowledgement of Receipt of Notice of Privacy Practices Date: Purpose: This form is used to obtain acknowledgement of receipt of our Notice of Privacy Practices or to document our good faith effort to obtain that acknowledgement. **You May Refuse to Sign This Acknowledgement** 1 have received a copy of Delaware Maryland Dental’s Notice of Privacy Practices, which describes how my health information is used and shared. | understand that Delaware Maryland Dental has the right to change this notice at any time. | may obtain a current copy by contacting the Facility Privacy Official., Print Patients Name:, Signature: Signatur We do call to remind you of appointments; Do you wish a reminder call?. if yes please list: Phone number May we leave a message on this number?. Office Use Only: ~~ ‘We attempted to obtain written acknowledgement of receot of our Notice Of Privacy Practons, but acknowledgment could not be obtsined because: —Hrvidual refused te sign Communication barriers prohibit obtaining the acknowledgement _—Dther(Please Speci —