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Health History Form

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

Preferred Method of Contact
Marital Status

If you are completing this form for another person, what is your relationship to that person?

Dental Information

Are your teeth sensitive to cold, hot, sweets or pressure?
Does food or floss catch between your teeth?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you ever had any problems associated with previous dental treatment?
Do you have earaches or neck pains?
Do you have any clicking, popping, or discomfort in the jaw?
Do you brux or grind your teeth?
Do you wear dentures or partials?
Have you ever had a serious injury to your head or mouth?
Are you currently experiencing dental pain or discomfort?

Medical Information

Are you currently under the care of a physician?
Are you in good health?
Has there been any change in your general health within the past year?
Do you use controlled substances (drugs)?
Do you use tobacco (smoking, snuff, chew, bidis)?
Have you had a serious illness, operation or been hospitalized in the past 5 years?
Do you take any blood thinners?
Do you take aspirin on a regular basis?
Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Women Only Are you:

Pregnant?
Taking birth control pills or hormonal replacements?
Nursing?
Have you ever had an orthopedic total joint (hip, knee, elbow, finger) replacement?

Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.

Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Metals
Latex (rubber)
Iodine
Hay fever / seasonal
Other

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

Heart murmur
Mitral valve prolapse
Artificial heart valves
Rheumatic fever
Cardiovascular disease
Angina
Congestive heart failure
Coronary artery disease
Damaged heart valves
Heart attack
Low blood pressure
High blood pressure
Congenital heart defects
Pacemaker
Rheumatic heart disease
Abnormal bleeding
Anemia
Blood transfusion
Hemophilia
AIDS or HIV infection
Arthritis
Autoimmune disease
Asthma
Bronchitis
Emphysema
Tuberculosis
Cancer / Chemotherapy / Radiation treatment
Chest pain
Chronic pain
Persistent swollen glands in neck
Kidney problems
Diabetes type I or type II
Eating disorder
Gastrointestinal disease
GE Reflux / persistent heartburn
Thyroid problems
Stroke
Glaucoma
Hepatitis, jaundice, or liver disease
Epilepsy
Fainting spells or seizures
Gag Reflex Sensitivity
Sleep disorder
Mental health disorders
Osteoporosis
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Do you have any disease, condition, or problem not listed above that you think we should know about?

Pharmacy Information

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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HIPAA Consent Form

General Information

Consent & Notice of Privacy Practices

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us by phone or email.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue
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Insurance Form

General Information

Primary Dental Insurance

Policy Holder
Relationship to Patient

Secondary Dental Insurance

Policy Holder
Relationship to Patient

If I am entitled to benefits under Medicare, Medicaid, or any insurance policy or other health benefit plan (covering me or anyone legally responsible for me), in consideration of services provided to me, I assign, transfer and convey the benefits payable under such program, policy or plan for services rendered to me. I authorize payment of these benefits directly, with such benefits being applied to my bill. I understand and acknowledge that this assignment does not relieve me of financial responsibility for charges incurred by me or anyone on my behalf, and I hereby acknowledge responsibility for and agree pay charges not paid under this assignment, including any coinsurance amounts, deductibles, Durable Medical Equipment, and any charges for service deemed to be non-covered, not pre-certified, or not pre-authorized by my insurance plan.

I give my consent for examination and treatment.

I authorize the release of information including the diagnosis, records, examination, treatment, radiology, and claims of information.

This information may be released to

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue
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Appointment Agreement Form

We make every effort to value your time and we schedule your appointment time just for you.

We truly appreciate your courtesy of giving us 48 hours notice if you have a conflict with your appointment and need to schedule a different day or time. We are committed to your oral health and keeping your scheduled appointments allows us to be partners in your dental care.

We will not charge for your first missed appointment. However, after two missed appointments in a 12 month span, you may be required to make a deposit when scheduling. If you keep the appointment the deposit will be applied towards treatment. However, if you fail to keep the appointment a second time, the deposit will be forfeited.

We ask that you confirm your appointment a minimum of 48 hours prior to your visit. You may confirm via email, text message or by calling our office during business hours. Failure to confirm to your appointment may result in the loss of the time reserved for you and your treatment and a loss of your deposit.

It is our philosophy to continue to put our patients first and to make your experience a positive one. Thank you for allowing us to share our appointment policy with you. Please let us know if you have any questions

Appointment Agreement

  • I acknowledge an appointment is a reservation.
  • I agree to provide a minimum of 48 hours notice if I need to change my appointment for any reason.
  • If I change 2 appointments without the required 48 hours notice in a 12 month span, I acknowledge I may be asked for a deposit at time of scheduling in order to be appointed.
  • I understand that I must confirm my appointment 48 hours prior to my appointment or forfeit the appointment and any and all deposit.
**Please be advised that cancellations made up to 48 hours before a scheduled appointment will be processed without a penalty. Cancellations made 48 hours or less before an appointment will be subject to a charge of $25, after 2 or more offenses. Feel free to contact our office at jsddsllc@gmail.com with any questions regarding this policy.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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Dental Treatment Consent Form

Local Anesthesia
I realize that there are risks involved in receiving local anesthesia. Some of these risks include: partial face paralysis, inflamed tissue, trismus, adverse reactions to drugs causing cardiac arrest, stroke, hemorrhage, nerve damage and/or numbness.

Changes in treatment plan
I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination. I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment outcome and have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to the proposed treatment.

Removal of teeth
Alternatives to removal have been explained to me (root canal therapy, crowns, periodontal surgery, etc.) and I authorize the Dentist to remove the following teeth. I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time (days or months) or fractured jaw. I understand I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment.

Restorations/Fillings
Fillings are procedures in which the dentist removes decayed tooth structure or a faulty restoration and replaces it with composite. I understand that these procedures could cause the teeth to be sensitive to hot and cold as well as chewing. The majority of the times, these sensitivities are temporary and they will go away within one or two weeks. However, there are times the depth of the decay in the tooth is greater than predicted by observation and dental radiographs and the tooth may need pulp treatment or root canal and/or crown. It is also possible that the pulp might already be infected by bacteria and become abscessed at some point after the filling procedure and require further treatment.

Crowns, Bridges
I understand that crowns and bridges are generally placed on teeth with extensive decay, large fillings, or fractures. These teeth have a greater chance of needing root canal therapy at a future date. If this future treatment is necessary, I understand that the fee is not included in the cost of the crown. I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth.

Dentures (Complete or Partial)
I realize that full or partial dentures are artificial, constructed of plastic, metal, and/or porcelain. The problems of wearing these appliances have been explained to me, including looseness, soreness, and possible breakage. I realize the final opportunity to make changes in my new dentures (including shape, fit, size, placement, and color) will be the “teeth in wax” try-in visit. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in the initial denture fee.

Endodontic Treatment
I understand that the purpose of a root canal or pulpotomy is due to deep decay into the pulp of the tooth. A root canal is performed in hopes of saving the tooth from extraction for the purpose of function. However, due to the fact that it is not possible to determine the extent of bacterial infection it is possible that even with best efforts, my tooth may become abscessed at some point after the pulp treatment and necessitate extraction. I realize there is no guarantee that root canal treatment will save my tooth, and complications can occur from the treatment.

I certify that I have read and fully understand the above consent to dental treatment and that the explanations therein referred to were made. Anything I did not understand has been explained to me.

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue
Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue