DENTAL INSURANCE INFORMATION
Is the patient covered by 2 dental policies? If so, please complete the following for secondary:
Are you currently seeing a physician or taking medications?
Do you have any known allergies to any type of metals?
Do you suffer from frequent headaches?
Have you had any significant injuries to your face and teeth?
HAVE YOU HAD OR CURRENTLY HAVE ANY HISTORY OF THE FOLLOWING?
Are there any medical conditions not listed above?
How often do you brush their teeth each day? (Check)
How often do you floss your teeth each day? (Check)
Have you had or have any of the following habits? (Check all that apply)
Have you had or have any of the following habits? (Check all that apply)
I certify that the above information is true, and to the best of my knowledge.
SLEEP ASSESSMENT AND EPWORTH SCALE
Please list any medical conditions within the last 5 years (hypertension, diabetes, surgery, etc.)
Check appropriate response:
Witnessed pauses in breathing while asleep?
Do you have difficulty falling asleep?
Do you have difficulty maintaining sleep?
Experience a restless sensation in legs while lying awake in bed? o
Kicking and twitching movements while asleep?
Experience excessive daytime tiredness?
Have you ever awakened feeling paralyzed?
Experience a sudden loss of strength in your arms or legs?
If the previous answer is Yes, were these events brought on by a sudden, frightening event or laughter?
Do you frequently awaken with:
According to the following scale choose the appropriate number value to represent how likely you are to fall asleep during the day in the
following situations. Try to be honest as possible. If possible, have your significant other help you fill this out.
0-Never 1-Slight chance 2-Moderate 3-Always
Sitting inactive in public (movie theater, meeting)
Sitting and talking to someone
Sitting quietly after lunch without alcohol
As a passenger in a car for an hour without a break
Driving a vehicle for 2 or more hours
Lying down to rest in the afternoon when circumstances permit
NOTICE OF PRIVACY PRACTICES (HIPAA)
This Notice Describes How Medical Information About You May Be Used And Disclosed
And How You Can Get Access To This Information. Please Review It Carefully.
Your protected health information (i.e. individually identifiable information, such as names, dates, phone/fax numbers, email addresses,
social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
- Your protected health information (i.e. individually identifiable information, such as names, dates, phone/fax numbers, email addresses,
social security numbers, and demographic data) may be used or disclosed by us in one or more of the following respects:
- To third party payers or spouses (i.e. insurance companies, employers with direct reimbursement, administrators of flexible spending
accounts, etc.) in order to obtain payment of your account (i.e. to determine benefits, dates of payment, etc.)
- To certifying, licensing and accrediting bodies (i.e. American Board of Orthodontics, state dental boards, etc.) in connection with
obtaining certification, licensure or accreditation.
- Internally, to all staff members who have any role in your treatment
- To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.
- To your family and close friends involved in your treatment
- To contact you in order to provide appointment reminders or information about treatment alternatives or other health related
benefits and services that may be of interest to you.
- To email your x-rays, photos, and treatment plan to your other doctors as needed.
- To leave messages or email you regarding upcoming appointments.
Your Rights Regarding Your Health Information
You may ask us to communicate with you in a confidential manner, ask to see or obtain photocopies of your health information and/or
ask us to amend your health information if you feel that it is inaccurate or incomplete.
Acknowledgments and Permissions
Please check all that you are acknowledging and granting permission!