� dK{��{m@�Jht�醡�Y�y9W���O���M��}`�VL� =� �)Szs��`��x�F:����/�<5g�rNA����\wm}��@� p��b� ���l{�[?��`�nm_‡�����K�b�ړs� �!K�7C���X��u���_RNj�_��QFm A#�{m�L�4���4�LXe�\Ϛ����j(&�����jtb��|c�5��lh��N4{�$��݀�N��. 0000057831 00000 n Such forms help hospitals choose the proper treatment and medication best suited for the patient, like if someone is allergic to a certain medicine, then you can choose alternative medicines for the patient. If you are a patient of record and have a dental emergency, you can call the of˜ice for information on how to contact us. That would be any allergies you might have if exposed to any food or medication, any current or past illnesses, family history of any illnesses, any surgeries whether major or minor, and current medications. If you have any questions please do not hesitate to call us. 0000064009 00000 n 0000006883 00000 n New Patients. Update Patient Information Form: This is used if any information on a Patient Information Form should be updated. Dental Patient Information Form: This is used by dental clinics or for patients with dental concerns. 0000113670 00000 n t. his authorization shall continue in effect until the undersigned revokes the same _____ _____ s. ignature of patient… ^�Th��0B�(�p�Q��$�^���@��B ����2���0Y New Patient Information Form: This is required by medical institutions when a patient is a first-time visitor. For most thi s is a ro utine procedure, but for many patients it is perhaps the hig hlight of their visit and the only point at which they will have to interact directly with you. 0000007836 00000 n 0000001483 00000 n As well, this information is not given away, sold, or used for anything other than Willamette Dental Group business. I will inform my dentist of any changes to my contact and/or Aspen Dental Appointment Guidelines. Patient Information Form . 0000008800 00000 n What are the types of Patient Information Forms? You should go over the Dental (Patient) Consent Form in full and answer any questions the patient may have clearly. i. also authorize the communication of information related to the coverage of services described to the named dentist. It is easy to make an appointment for your initial examination and dental treatments. Patient Health Information Form: This form lists the patient’s information and the patient can choose which information can be released or disclosed. 0000005958 00000 n In case of minor patients, it is required that one of the parents or legal guardian accompany the child and remain in the waiting room during all procedures. Consent to Communicate PHI by Email Form - Spanish (.pdf) Requesting Dental Records If you need copies of your dental records and/or radiographs, please print, complete and sign both the Consent to Release Health Information and the Consent to Communicate PHI by Email forms below and return them to the College of Dentistry. You can find more Patient Information Forms below. If you need your information to be disclosed to any other organization, you would need to sign Release of Information Forms for this purpose. 0000038978 00000 n Birthdate C) Single SS# State Email Name Address Sex F Home Phone # ( Employer Employer Address C] Married Separated • To the best of my knowledge, all of the proceeding information is true and correct. 0000039986 00000 n 0000002829 00000 n 0000002071 00000 n Arthur Family Dental, LLC Patient Information Form Health History Form 2019.doc Staff Initials _____Date _____ Health Questions Any history of heart murmur/MVP or any other heart problems? Cut out pesky paperwork and enjoy the benefits of a smoother patient intake process with our Dental Health Record Template. Patient Relationship to Insured _____ To the best of my knowledge, the above information is correct. information contained in claims submitted electronically. 0000003856 00000 n 0000009763 00000 n New Patient Information Form: This is required by medical institutions when a patient is a first-time visitor. The dental examination The dental examination is one of the most important, under-appreciated or even mis-understood components of the dental visit. 0000001606 00000 n 0000074110 00000 n 0000060918 00000 n 0000003144 00000 n This is a tool that helps them to provide each patient with the proper medical treatments and medication while considering any present medical conditions or allergies the patient may have. This can also ultimately lead to a hassle-free billing process. Dental Emergency Information. 0000004219 00000 n What information is included in Patient Information Forms? The dental insurance verification form is a document used by a dental care facility when requesting the insurance information of a patient. PATIENT INFORMATION Widowed Divorced Cell Phone # Thank you for trusting us with your dental care. For patients under the age of 18, a parent or guardian will need to sign the consent form. %PDF-1.6 %���� Aspen Dental is scheduling appointments according to ADA, state, and local guidance. 0000004676 00000 n as well as any other aspect pertinent to the policy. 0000003602 00000 n This is usually requested by the patient. 0000113273 00000 n 118 0 obj <> endobj xref 118 36 0000000016 00000 n I authorize the release of any information concerning my (or my child’s) healthcare, advice, and treatment to another dentist. With this information, you will know what the trends are when it comes to which types of individuals usually get certain illnesses. 0000002430 00000 n %l��C�n��i.3�ౙ���3����|������V�ٷ)���M@�L�������քu���}1�3S9�ESGƶ�7ڢ��� �ƺ1%*�xI�G��C% Patient Name:_____ _____ Date of birth:_____ Sex:____ Age:____ Home Address :_____ _____ City:_____ State:_____ Zip :_____ Have patients fill out their information on a computer or tablet using an online Dental Health Record Form, then use PDF Editor to easily format the data into a polished PDF document for the patient’s file. 0000003970 00000 n Besides patient and insurance information and a thorough medical history, it includes a welcoming introduction, "Thank you for choosing our office to assist you with your dental needs." We accommodate patients of record who experience dental emergencies after hours. This is to certify that I, undersigned, consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of the local anaesthetic as indicated and I will assume responsibility for fees associated with those procedures. If you are experiencing a dental emergency, please call us immediately and we will do everything we can to create an immediate appointment for you. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that ... to telephone me at home or at my work to discuss matters related to this form. Personal Information Forms are required by every hospital or medical institution when you have yourself checked, when you are admitted, or when you undergo any medical procedure. Recording patient data regarding race and ethnicity will allow Willamette Dental Groupto better understand and meet our patients’ o ral health needs. trailer <<134CCBD2BB6E48419E4BADE4E49EE841>]/Prev 160699/XRefStm 1312>> startxref 0 %%EOF 153 0 obj <>stream Many practices have tried to streamline new patient dental form by putting intake PDF file forms on their website so their patients will be able to fill out the paperwork at home. A few things have changed since we last saw you. h�bbd`b``�� �T6 endstream endobj 119 0 obj <>/Metadata 19 0 R/Pages 18 0 R/StructTreeRoot 21 0 R/Type/Catalog>> endobj 120 0 obj <>/ExtGState<>/Font<>/ProcSet[/PDF/Text/ImageC]/XObject<>>>/Rotate 0/StructParents 0/Tabs/S/TrimBox[0.0 0.0 612.0 792.0]/Type/Page>> endobj 121 0 obj <> endobj 122 0 obj <> endobj 123 0 obj <> endobj 124 0 obj <> endobj 125 0 obj <> endobj 126 0 obj [/ICCBased 145 0 R] endobj 127 0 obj <> endobj 128 0 obj <> endobj 129 0 obj <> endobj 130 0 obj <> endobj 131 0 obj <> endobj 132 0 obj <> endobj 133 0 obj <>stream Patient Demographic Information Form: The purpose of this form is to categorize the patients based on their demographics for the purpose of statistical analysis. 0000113606 00000 n 0000061360 00000 n It also gently reminds patients to read all the way to the end in order to make sure they provide their signature. The dental patient form print’s out typically 5-7 pages and fills it in by hand and then the front office is sometimes left trying to decipher the information as well as taking a time to properly file it. h�b```a``�c`e`jed@ A�P���� @���9KP gK�)9f%�T��2���s>1J:��zb�DEEGG�RR�2B�@�q �� As hassle as filling out these patient forms could prove to be, once you understand the rationale behind them, you will begin to appreciate their importance. If I ever have a change in my health, I will inform the office at my next dental … 0000110684 00000 n 0000010730 00000 n 0000004956 00000 n Dental Patient Information Form: This is used by dental clinics or for patients with dental concerns. It also helps with demographics and statistical analysis. When transferring information to another dental office we only send current x-rays (bitewing x-rays, full mouth x-rays & panorex) within the last 5 yrs and treatment dates for prophy’s (cleanings) – exams – scale & root planning. 0000001312 00000 n Under medical history, there are a number of information bits that have to be included. 0000004587 00000 n Update Patient Information Form: This is used if any information on a Patient Information Form should be updated. This can also be necessary for disease prevention. Here’s what to expect with our Smile Wide, Smile Safe Promise. An after hours fee may be charged. The consent forms and disclosure agreements are necessary so the hospital will not have any legal liability issues. The form should be sent to the patient’s insurer so that they may detail the type of medical work which will be covered by the patient’s plan (preventative, major, periodontal, etc.) It also shows that the patient is fully aware and chooses to get treatment and medication. PDF Download. 0000011625 00000 n You may also want to fill out a Medical Information Form for any medical emergency. H��V�n�0��+؛�_��c�C�^Z�z(�B��؅#��4ߕ��C2�^g%jggg���Z�����eu_U�pR�W�S�#���4ӌ�\e�G��Z���� 0000001016 00000 n I accept the above conditions and hereby voluntarily give consent to Truman Medical Center Lakewood Dental Clinic and the dental staff to provide dental care encompassing routine diagnostic PATIENT CONSENT • I authorize Carmi Family Dental to perform all recommended treatment agreed upon by myself and my doctor. 0000003565 00000 n @�֡� ���щ1�������&�/�Fo���G�+��0�g�Ǽ�9*k�i� ܯ�r��������� � 4������!�Fx��U0�fz�� �—Q�U � 6 endstream endobj 152 0 obj <>/Filter/FlateDecode/Index[21 97]/Length 22/Size 118/Type/XRef/W[1 1 1]>>stream A patient of record is one who has been seen and treated in the of˜ice during the past 18 months. We promise to do our best to provide you with the finest care available. If you have a dental emergency, call us at 1-855-978-1628. Personal information of the guarantor or the person in charge of the medical bills, Patient’s medical history, including previous illnesses, hospitalizations, and surgeries, A consent form and a disclosure agreement when necessary. 0000002986 00000 n Patient Information Form Preferred Name: Zip Divorced City Cell # Single Spouse Group # Spouse Group # Married State Work # DOB Phone Circle one: Other Minor Person to contact in case of an emergency Whom may we thank for referring you Insurance Information Primary Policy Holder Name Relationship to policy holder Policy Holder DOB Insurance Compay Adult Medical and Dental History Form #201 Patient Name _____ D.O.B. The main thing is that the patient understands any risks involved before they consent to treatment. Call 480-814-8888 to speak with a staff member and you can download the New Patient Form … Gently reminds patients to read all the way to the policy to do our best to provide you with finest! 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