Dental Health Guides
Dental Forms
Patient Informaton
( You may print this page and fill it out before you come in. It will save time and you can relax with no worried when you get here! )
NAME: ____________ ___ _____________ DATE: _________ SS/HIC/PATIENTID# ______________
FIRST MI LAST
ADDRESS: _______________________ CITY: _________________STATE: ____ ZIP: ____________
SEX: __FEMALE __MALE BIRTHDATE: ___/___/_______ E-MAIL: ______________________________
HOME PHONE: (___)____-______ CELL PHONE: (___)____-______ WORK PHONE: (____)____-______
DO YOU PREFER TO RECEIVE CALLS AT: __HOME __WORK __CELL __NO PREFERENCE
__ MARRIED __WIDOWED __MINOR __SEPARATED __DIVORCED PRTNR FOR ___ YEARS
PATIENT EMPLOYER/SCHOOL: _______________________ OCCUPATION: ______________________
SPOUSE OR PARENT’S NAME: _______________EMPLOYER:__________ WORK #: (___)____-______
WHOM MAY WE THANK FOR REFERRING YOU TO US? ______________________________________
PERSON TO CONTACT IN CASE OF EMERGENCY:___________________ #: (___)_____-______
RESPONSIBLE PARTY
Name of person responsible for this account: _____________________________
Relationship to patient:___________________________ phone#: (___)____-_____
Address:______________________City:______________State:____ Zip:________
Name of employer:_________________________ work#: (____)______-________
Insurance Information
Name of insured____________________ relationship to patient______________
Birthdate__/__/______ SS#____________________ date employed__/__/_____
Name of employer______________________________ work# (___)____-______
Address of employer___________________ City__________ State__ Zip______
Insurance CO____________________ Group#___________ employer#________
Insur. CO Address____________________ City__________ State__ Zip_______
How much is your deductable?___________ how much used?______ max. annual benefit? ___
DO YOU HAVE ADDITIONAL INSURANCE? __no __yes
(if yes complete the following)
Name of insured____________________ relationship to patient______________
Birthdate__/__/______ SS#____________________ date employed__/__/_____
Name of employer______________________________ work# (___)____-______
Address of employer___________________ City__________ State__ Zip______
Insurance CO____________________ Group#___________ employer#________
Insur. CO Address____________________ City__________ State__ Zip_______
How much is your deductable?___________ how much used?______ max. annual benefit? ___
MEDICAL HISTORY
Physician:____________________________ date last visit: ___/___/______
List of medications you are currently taking:__________________________
Allergies:_____________________________________________________
(women) pregnant? _yes_no nursing? _yes_no on birth control? _yes _no
check if you have had any of the following:
__AIDS __Hepatitis
__Anemia __Hernia Repair
__Arthritis, Rheumatism __High Blood Pressure
__Artificial Heart Valves __HIV Positive
__Artificial Joints __Jaw Pain
__Asthma __Kidney Disease
__Back Problems __Liver Disease
__Bleeding Abnormally __Mitral Valve Prolapse
__Blood Disease __Nervous Problems
__Cancer __Pacemaker
__Chemical Dependency __Psychiatric Care
__Chemotherapy __Radiation Treatment
__Circulatory Problems __Respiratory Disease
__Congenital Heart Lesions __Rheumatic Fever
__Cortisone Treatments __Scarlet Fever
__Cough, Persistent __Shortness of Breath
__Cough up blood __Skin Rash
__Diabetes __Stroke
__Epilepsy __Swelling of Feet or Ankles
__Fainting __Thyroid Problems
__Glaucoma __Tobacco Habit
__Headaches __Tonsillitis
__Heart Murmur __Tuberculosis
__Heart Problems __Ulcer
describe:________________ __Venereal Disease
__Hemophilia
Have you ever taken any of these medications?
Diet Medications: __Dexfenfluramine __Fen-phen __Pondimin __Redux
Blood Thinners: __Coumadin __Warfarin
Other: __Levoxyl __Synthroid
Certification and Assignment
To the best of my knowledge, the above information is complete and correct. I understand that it is my responsiblity to inform my doctor if I, or my minor child, ever have a change in health.
I certify that I, and/or my dependent(s), have insurance coverage with _____________________ and assign directly to Dr. __________________
all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpaose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
________________________________________ __________
Signature of patient, parent, guardian, or personal rep. date
________________________________________ __________
print name of patient, parent, guardian, or personal rep. date
__________________________
H.I.P.P.A Privacy Notice
ACKNOWLEDGEMENT OF RECEIPT OF NOTIVE OF PRIVATE PRACTICE PRACTICES
***You may refuse to sign this acknowledgement***
I, ____________________________, have received a copy of this office Notice of Private Practice.
_______________________________
(Printed Name)
__________________________________
(Signature)
__________________________________
(Date)
_________________________________________________________________
_________________________For office use only_________________________
We attempted to pbtain written acknowledgement of receipt of our Privacy Practices, but acknowledgement could not be obtained for the following reason:
__ Individual Refused to sign
__ Communivation barriers prohibited obtaining information
__ Emergency aituation prevented us from obtaining acknowledgement
__ Other (please specify)
____________________________________
Zoom Post-Op Instructions
You may experience an electric sensation in your teeth a few hours after the Zoom procedure called "zingers." This should last only a few hours and could be mild to severe depending on the person and will be gone by the next day. Take the prescribed pain medicine to control the discomfort.
DO NOT eat any types of food that have any staining properties to them.
Avoid such foods as chili, spaghetti, red wine, coffee/tea, mustard, and dark sodas for the next 48 hours. Your teeth are dehydrated and will accept staining food easily.
Denture Placement Instructions
If you had multiple extractions the same day as denture insertion, DO NOT remove denture for 24 hours. Due to swelling, you may not be able to get your denture back in your mouth.
The day after the denture was placed, you may remove denture from your mouth and rinse with warm salty water; be careful not to touch sutures. You may rinse the denture with cool tap water and replace back in mouth.
Remove the denture every night and place it in a denture bath. Your gums need a break from wearing them all day.
If an area in your mouth develops a sore spot, call the office and make an appointment for a denture adjustment as soon as possible and continue to wear the denture so that we adjust the appropriate area.
Crown Appointment Post-Treatment
Take ibuprofen immediately following procedure to relieve any minor discomfort.
Use warm salty water rinses for a few days to help relieve inflammation.
Avoid any chewy/sticky (including gum) or hard/crunchy foods in the area.
If your temporary cracks, please contact our office during normal business hours. It is important that your temporary crown stay intact to ensure a proper fit of your permanent crown.
If your temporary crown comes off, place it back on using toothpaste or denture adhesive (e.g. Fixodent) to hold it in and call to be seen as soon as possible.
If you experience any heat or pressure sensitivity before your cementation appointment, please contact our office during normal business hours.
When flossing your temporary crown, pull the floss between teeth, and then gently slide the floss through so that your crown will not pop off.
Care of Mouth after Extraction
Do not rinse mouth the day of surgery, the following day is acceptable. Rinse mouth gently every 3 to 4 hours (especially after meals) using one-quarter teaspoon of salt to a glass of warm water. Continue rinses for several days.
Bleeding - Following extractions, some bleeding is to be expected. If persistent bleeding occurs, place gauze pads over bleeding area and bite down firmly for one-half hour. Repeat if necessary.
Swelling - Ice bag or chopped ice wrapped in a towel should be applied to operated area for one hour and then off for 4-5 hours.
Pain - For mild to average pain, use any aspirin-type of medication you like.
Food - Light diet is advisable during the first 24 hours, such as ice cream, pudding, yogurt, and jello. (Cool foods only, nothing hot)
Bony Edges - Small, sharp bone fragments may work up through the gums during healing. These are not roots; if you find it annoying, return to this office for their simple removal.
ABSOLUTELY NO SMOKING FOR 24 HOURS
If any unusual symptoms occur, contact the office immediately at (843) 761-1600 or during after hours at (843) 303-1700.The proper care following oral surgical procedures will hasten recovery and prevent complications.