ADULT PATIENT
INFORMATION
GETTING TO KNOW YOU...
WHAT ARE YOUR GOALS?
DENTAL INSURANCE INFORMATION
EMERGENCY INFORMATION
MEDICAL HISTORY

Have you had or currently have any history of the following?

DENTAL HISTORY
ADDITIONAL INFORMATION

I certify that the above information is true, and to the best of my knowledge.


SLEEP ASSESSMENT AND EPWORTH SCALE

Check appropriate response:

Check all that apply:

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

John F. Monacell, D.D.S., P.C.

Specialist in Adult & Child Orthodontics and Dentofacial Orthopedics

1343 East Williamsburg Road • Sandston VA 231509448 Chamberlayne Road, Suite B • Mechanicsville VA 23116

  • (804) 737-6757
  • www.monacellorthodontics.com
  • (804) 746-0918
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 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.

Acknowledgements and Permissions

PLEASE INITIAL OR WRITE "NO" ON THE FIRST TWO LINES. INITIAL THE THIRD LINE!

I hereby acknowledge that I have received, read and reviewed a copy of this notice of Privacy Practices, the consent to treatment and office procedures. I authorize use of my signature on and release of information for insurance submissions.


John F. Monacell, D.D.S., P.C.

Specialist in Adult & Child Orthodontics and Dentofacial Orthopedics

1343 East Williamsburg Road • Sandston VA 231509448 Chamberlayne Road, Suite B • Mechanicsville VA 23116

  • (804) 737-6757
  • www.monacellorthodontics.com
  • (804) 746-0918