DCIYH

Dental Care In Your Home, Inc.

INSTRUCTIONS FOR FILLING OUT THE NEW PATIENT FORMS

If a question is asked, that does not apply; a response must be given even if it is "Not Known" or N/A.

Please answer all questions on the PATIENT REGISTRATION page.
Please fill in all of your information on the MEDICAL HISTORY page.
Please fill in your entire information DENTAL INSURANCE INFORMATION page.
The AUTHORIZATION/INFORMED CONSENT page must be signed.
The HIPAA (Health Insurance Portability and Accountability Act) Form must be signed.

PATIENT REGISTRATION

First Name *

Middle Initial *

Last name *

Preferred Name *

Date of Birth *

Male or Female *

Address *

City, State, Zip Code *

Social Security Number *

Driver License Number *

Home Phone *

Cell Phone *

Marital Status (Married, Single, Divorced,Seperated,Widowed) *

Emergency Contact *

Contact's Phone Number *

How were you referred to our service/practice? *

RESPONSIBLE PARTY (If other than patient)

First Name *

Middle Initial *

Last name *

Preferred Name *

Relationship to Patient: *

Address: *

City, State, Zip: *

Social Security Number: *

Drivers License Number: *

Home Phone Number: *

Cell Phone Number: *

Email Address: *

DENTAL INSURANCE INFORMATION (if applicable)

PRIMARY DENTAL INSURANCE

Name of Insured: *

Relationship tp Patient: *

Insured Social Security No: *

Insured Date of Birth: *

Insurance Company: *

Address of Insurance Company: *

Insurance Company’s Phone Number: *

Group Number: *

Member ID Number: *

SECONDARY DENTAL INSURANCE

Name of Insured: *

Relationship tp Patient: *

Insured Social Security No: *

Insured Date of Birth: *

Insurance Company: *

Address of Insurance Company: *

Insurance Company’s Phone Number: *

Group Number: *

Member ID Number: *

MEDICAL HISTORY

Although Dental personnel primarily treat the area in and around your mouth, your mouth is a part of the entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive.

Thank you for answering all of the following questions

Are you currently under a Physician’s care (Yes or No)? *

If YES, please explain: *

Physician’s Name: *

Physician’s Phone Number: *

Preferred Pharmacy: *

Pharmacy Phone Number: *

Current Health: Excellent, Good, Fair, Poor (Enter 1 of 4 Choices) *

Have you visited an Emergeny Room for Oral Pain or Infection? (Answer Yes or No) if Yes, Please Explain: *

Have you had any serious health issues in the past 5 years? (Answer Yes or No) if Yes, Please Explain: *

Are you taking any medications (Yes or No)? If YES, please list all medications: *

Do you need to take an antibiotic premedication prior to dental treatment? Yes or No *

Do you need an anxiety premedication prior to dental treatment? Yes or No *

Please List Below Anything You are Allergic to. Examples Include but not Limited to: Local Anesthesia, Penicillin/Other Antibiotics, Barbiturates, Aspirin, Sedatives, Sleeping Pills, Sulfa Drugs, Shellfish, Red Wine, Codeine/Other Narcotics, Iodine, Latex, Any Other *

Please List Below any & all of the Following You Have or Had in the Past. Examples Include, but not Limited to:

A-Fib, Alzheimer’s Disease, Anaphylaxis, Anemia, Arthritis/Gout, Artificial Joint, Asthma, Autism, Blood Disease, Bruise Easily, Cancer, Chest Pains, Congenital Heart Disorder. Convulsions, COPD, Dementia, Diabetes, Epilepsy/Seizures, Fainting/Dizziness, Glaucoma, Heart Attack/Failure, Heart Disease, Heart Murmur, Heart Pace Maker, Hemophilia, Hepatitis, High Blood Pressure, Hypertension, Hypoglycemia, Kidney Disease, Leukemia, Liver Disease, Low Blood Pressure, Mitral Valve Prolapse, Pain In Jaw Joints, Parkinson’s, Psychiatric Care, Radiation Treatment, Recent Weight Loss, Renal Dialysis, Rheumatic Fever, Rheumatism, Shingles, Sinus Troubles, Spina Bifida, Stomach/Intestinal Disease, Stroke, Swelling of Limbs, Thyroid Disease, Tumors/Growths, Ulcers *

DENTAL INFORMATION

So that we can serve your dental needs according to your expectations, we would like to ask you a few questions.

What is your main concern with your teeth and gums? *

How long has it been since your most recent dental care? *

What was done at that appointment? *

If you have dentures/partials, When were they made? *

Have they ever been relined? *

How do they fit? *

Are you apprehensive about dental care? *

Will you let another person help you with your dental care? *

How often would you like to have Dental Care In Your Home clean your teeth? *

AUTHORIZATION/INFORMED CONSENT

I understand that myself or my representative will be informed of my dental ailments, treatment options, benefits, substantial risks and consequences of limited or non-treatment. I consent to authorize dental services to be performed. I understand that at any time I may terminate or postpone dental treatment.

If you have dental insurance, we will help you receive your maximum allowable benefits. We will gladly discuss your treatment and answer any questions relating to your insurance to the best of our ability. As a courtesy, we will file your dental claims, but will not accept responsibility for negotiating any settlement on disputed claims. I understand that my dental insurance is a contract between my insurance carrier and me and not between the insurance carrier and Dental Care In Your Home, Inc. Therefore, I am still responsible for all dental fees. I understand that I will charged for all dental treatment and that any payments received by Dental Care In Your Home, Inc. will be credited to my account.

I hereby authorize Dental Care In Your Home, Inc., to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on my dental and medical histories is correct to the best of my knowledge. I grant the right to release my dental/medical histories and other information about my dental/medical histories and other information about my dental treatment to third party payors and/or other health professionals

I understand and acknowledge that I have read, understand and agree to aforementioned policies.

Signature of patient or personal representative: *

clear

Printed Name of Patient or Personal Representative: *

Relationship to patient: *

Date: *

HIPAA Privacy Authorization Form

Authorization for Use or Disclosure of Protected Health Information. (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164)

AUTHORIZATION: I authorize Dental Care In Your Home, Inc. to use and disclose the protected health information described below to my insurance company or specialist or my physician.

EFFECTIVE PERIOD: This authorization for release of information covers the period of health care beginning *

This medical information may be used by the person I authorize to receive this information for dental treatment or consultation, billing or claims payment, or other purposes as I may direct.

This authorization shall be in force and effect until I withdraw this authorization in writing, at which time this authorization expires.

I understand that I have the right to revoke this authorization, in writing, at any time. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to contest a claim.

I understand that my treatment, payment, enrollment or eligibility for benefits will not be conditioned on whether I sign this authorization.

I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.

Signature of patient or personal representative: *

clear

Printed name of patient or personal representative: *

Relationship To Patient *

Date: *