Patient Information

Patient Name etaD :

Last, First MI (Preferred Name)

Social Security #: Birth Date: Driver’s Lic #:

Phone (Home): (Work): Ext:

Address: Street Apartment #

City State Zip Code

Health Information

Do you have any of the following? Please check those that apply: Allergies

__________

__________ Anemia Arthritis Artificial Joints Asthma Blood Disease Cancer Diabetes Dizziness

Excessive Bleeding Fainting Glaucoma Head Injuries Heart Disease Heart Murmur Hepatitis High Blood Pressure H.I.V. Kidney Disease Liver Disease

Mental Disorders Anxiety Disorders

Nervous Disorders Pacemaker Pregnant

Due date:_________ Radiation Treatment Respiratory Problem

s

Rheumatic Fever Sinus Problems Stomach Problems

Tumors Ulcers Codeine Allergy Penicillin Allergy

OTHER:

____________________

____________________

• Have you ever had any complications following dental treatment? Yes No If yes, please explain:

• Have you been admitted to a hospital or needed emergency care during the past two years? Yes No If yes, please explain:

• Are you now under the care of a physician? Yes No If yes, please explain:

• Name of Physician: _______________________________________________ Phone: ••

Do you have any health problems that need further clarification? Yes No If yes, please explain: Please list any medications you may be taking____________________________________________________ __________________________________________________________________________________________

To the best of

In case of emergency, who should we notify? Name:________________________________________________Relationship:__________________________________ Phone:________________________________________

my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.______________________________________________________________________ Date: Signature of patient, parent or guardian

Referral Information Whom may we thank for referring you to our practice? Another patient (relative) Another patient (friend)

Internet Yellow Pages Facebook Google Yelp Other

Name of patient/person or office referring you to our practice

Cell phone E-mail address

Epilepsy

Stroke

Tuberculosis

Male Female Married Single Child Other

RESPONSIBLE PARTY INFORMATION (Children Under 18)The following is for the person responsible for payment

Name: Birth Date: ________________ Male Female Married Single Child Other

Social Security #: _____________________________ Driver’s License #: _____________________________

Cell Phone: _________________________________ Phone (Home): __________________________________Address: Street Apartment # City State Zip Code

Patient’s Employment Information

:noitapuccO :emaN reyolpmE

Insurance Information Primary Insurance Insurance Co. Name/Address:_______________________________Group #: _____Subscriber ID___________

Name of Insured: ________________________ Insured's Birth Date: __/__/___Is insured a patient? Yes No

Insured's Social Security #: Driver’s License #:

Insured's Employer Name:

Patient's relationship to insured: Self Spouse Child Other _________________________________ Secondary Insurance

Insured's Address: Street City State Zip Code

Insurance Co. Name/Address:_______________________________Group #: _____Subscriber ID___________

Name of Insured: ________________________ Insured's Birth Date: __/__/___Is insured a patient? Yes No

Insured's Social Security #: Driver’s License #:

Insured's Employer Name:

Patient's relationship to insured: Self Spouse Child Other _________________________________

Insured's Address: Street City State Zip Code

Consent for Services As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

****ALL DENTAL SERVICES PERFORMED WITHOUT PREVIOUS FINANCIAL ARRANGEMENTS MUST BE PAID FOR AT THE TIME SERVICES ARE PERFORMED ****

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company. I also authorize insurance payments to be made directly to this dental office.

A service charge of 1½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied. For returned checks, I agree that my account will be debited electronically for the face amount, returned check fee and returned deposit item fee if returned unpaid.

I understand that fee estimates listed for dental care can only be extended for a period of three months from the date of the patient examination. Insurance co payment quotes are ALWAYS AN ESTIMATE! We fully advise you to be aware of your insurance benefits! KNOW YOUR PLAN AND HOW IT WORKS! Call your insurance carrier for exact details of your coverage.In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form.I grant my permission to Dr. Randall Furman to treat me and or my dependent children as deemed medically necessary.

II give my consent for Dr. Furman to treat my dependents (under 18) as he sees necessary. have read the above conditions of treatment and payment and agree to their content.

__________________________________________________________________ Date: _______________ Relationship to Patient: Signature of patient, parent or guardian

PATIENT PRIVACY CONSENT FORM The Department of Health and Human Services has established a “Privacy Rule” to help

insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patient’s consent for uses and disclosures of health information about the patient to carry out treatment, payment or health care operations.

As our patient, we want you to know that we respect the privacy of your personal dental records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, we will provide the minimum amount of necessary information to only those whom we feel are in need of your health care information regarding treatment, payment or health care operations in order to provide health care that is in your best interest.

We also want you to know that we support your full access to your personal dental records. We may at times have indirect treatment relationships regarding you as a patient, such as laboratories that only interact with doctors and not the patient directly. At those times we may have to disclose personal health information for the purpose treatment, payment and/or health care operations. These entities are most often not required to obtain direct patient consent.

You may refuse to consent to the use or disclosure of your personal health information in writing. Therefore, under this law, we have the right to refuse to treat you should you choose to refuse to disclose your Personal Health Information (PHI). At anytime in the future you may request in writing to refuse all or part of this document that you are signing today. You may not revoke previous actions taken, which have relied on this, or an earlier signed consent.

If you have any objections to this form, please ask to speak to our HIPAA Compliance Officer.

You have the right to review our privacy notice, to request restrictions or revoke consent in writing after you have reviewed our privacy notice.

PRINT NAME:__________________SIGNATURE:______________DATE:_______

----------------------------------------------------------------------------------------------------------- COMPLIANCE ASSURANCE NOTIFICATION FOR OUR PATIENTS

To our valued patients: The misuse of Personal Health Information (PHI) has been identified as a

national problem causing patients inconvenience, aggravation and money. We want you to know that all of our employees, managers and doctors continually undergo training so that they may understand and comply with government rules and regulations regarding the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the “privacy rule”. We strive to achieve the very highest standards of ethics and integrity in performing services for our patients.

It is our policy to properly determine appropriate use of PHI in accordance with the government rules, laws and regulations. We want to ensure that our practice never contributes in any way to the growing problem of improper disclosure of PHI. As a part of this plan, we have implemented a Compliance Program that we believe will help us prevent any inappropriate use of PHI.

DENTAL HISTORY FORM

1. What is the main reason for your visit today? ____________________________________________

Name ____________________________________________

___________________________________________________________________________________ 2. How long has it been since your last dental cleaning and exam with x-rays? ___________________

3. Name one thing you liked MOST about your last dentist. __________________________________ ___________________________________________________________________________________

DOES YOUR DENTAL HISTORY INCLUDE ANY OF THE FOLLOWING CONDITIONS?

YES NO

___ ___ Are any of your teeth sensitive to hot or cold, sweets or chewing? (please circle)

___ ___ Are you dissatisfied with the appearance of your smile?

___ ___ Have you ever been treated by a periodontist? (gum doctor)

___ ___ Do you smoke?

___ ___ Have you ever had scaling or root planning (deep cleaning) for periodontal disease?

___ ___ Do your gums bleed after brushing and flossing?

___ ___ Have you ever been told you have “gum disease”?

___ ___ Are you worried about bad breath? (halitosis)

___ ___ Is it uncomfortable to have your teeth cleaned in the dental office?

___ ___ Have you ever worn braces? (orthodontics) Orthodontist’s Name __________________________

___ ___ Are you aware of grinding your teeth at night?

___ ___ Does your jaw joint by your ears ever click or pop or make noises?

___ ___ Do you ever have facial pain in the muscles or jaw joints near your ears? ___ ___ Do you have frequent headaches? If yes, where? _________________

___ ___ Have you ever been told you have TMD or TMJ?

___ ___ Have you ever worn a nightguard?

___ ___ Are you overly afraid of going to the dentist?

___ ___ Have you ever had any serious problems with prior dental visits?

___ ___ Do you have any missing teeth?

___ ___ If you do have missing teeth, are you interested in replacing them?

___ ___ Do you wear a partial/denture? If so, how old is the partial/denture? ________ years.

___ ___ Would you like to be placed on a 6 month cleaning and examination schedule? (As recommended by the American Dental Association)

___ ___ Are you available for appointments on short notice?