Patient Information
Patient's Name:
Nickname:
Date of Birth:
Age:
Sex:
Male
Female
Address:
City:
Zip:
Home Phone:
E-Mail:
Cell Phone:
Cell Phone Carrier:
Preferred Method of Communication:
Text
E-Mail
Phone
Employer:
Occupation:
Marital Status:
Single
Married
Divorced
Widowed
Emergency Contact Name:
Emergency Contact Phone #:
Relationship:
General Dentist:
When was your last Cleaning?
How did you hear about us?
Responsible Party:
Self
Other(Name)
(Address)
(Phone #)
Is patient covered by insurance for dental treatment?
Yes
No
Insurance Company
Subscriber Name
DOB:
Subscriber’s Social Security Number
What are the main concerns that you would like to discuss?
Has there been any changes in your general health within the past year?
Yes
No
Please specify:
Are you under the care of a physician for a current problem?
Yes
No
Please specify:
Have you been hospitalized within the past five years?
Yes
No
Please specify:
Have you received therapy for alcoholism or drug addiction?
Yes
No
Have you had abnormal bleeding with previous dental treatment/surgery
Yes
No
Have you ever required a blood transfusion?
Yes
No
Have you ever had radiation therapy?
Yes
No
Location:
Do you have any artificial joints/prosthesis?
Yes
No
Explain:
Have you been tested for HIV/AIDS?
Yes
No
Have you been diagnosed with cancer?
Yes
No
Are you or could you be pregnant right now?
Yes
No
Are you currently Breastfeeding?
Yes
No
Are you currently taking birth control
Yes
No
Have you ever had any of the following
medical problems?
Y
N
Abnormal Bleeding
Y
N
Anemia
Y
N
Artifical Bones/Joints/Valves
Y
N
Autoimmune Disorders
Y
N
Blood Transfusion
Y
N
Congenital Heart Defect
Y
N
Cancer/Chemotherapy
Y
N
Difficulty Breathing
Y
N
Drug/Alcohol Abuse
Y
N
Emphysema
Y
N
Epilepsy/Seizures/Fainting
Y
N
Fever Blisters/Herpes
Y
N
Glaucoma
Y
N
Heart Attack/Stroke
Y
N
Heart Murmur
Y
N
Heart Surgery/Pacemaker
Y
N
Diabetes
Y
N
Hepatitis
Y
N
High/Low Blood Pressure
Y
N
Hospitalized for Any Reason
Y
N
Kidney Problems or Dialysis
Y
N
Mitral Valve Prolapse
Y
N
Psychiatric Problems
Y
N
Radiation Treatment
Y
N
Rheumatic/Scarlet Fever
Y
N
Severe/Frequent Headaches
Y
N
Shingles
Y
N
Sickle Cell Disease/Traits
Y
N
Sinus Problems
Y
N
Tuberculosis (TB)
Y
N
Ulcers/Colitis
Y
N
Venereal Disease
Are you
allergic
to any of the following?
Y
N
Aspirin
Y
N
Penicillin
Y
N
Erythromycin
Y
N
Codeine
Y
N
Other
Y
N
Dental Anesthetics
Y
N
Any Metals/Plastics
Y
N
Tetracycline
Y
N
Latex
Current medications
you are taking:
Have you taken drugs for osteoporosis such as Fosamax, Actonel, Boniva, Aridia, or Zometa?
Y
N
I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status.
Signature:
Date
Renton Endodontics Financial Policy
Thank you for selecting our office for your endodontic treatment. If you have dental insurance coverage, we are happy to submit and file your dental claims as a courtesy if you agree to accept assignment of benefits. However,
the patient or guardian is ultimately responsible for all fees and services rendered
at our practice, including any amount not covered by insurance. Our staff will pre-credit your account for the insurance portion prior to treatment.
The estimated copay is due at the time of service.
Once we have processed your insurance payment, any remaining balance will be due within 28 days to avoid a monthly late fee. A $50 rescheduling fee will apply should you cancel/reschedule in less than 48 hours.
We offer a variety of payment options including cash, cashier’s checks, credits cards. In addition, should you be interested in longer term financing, we offer Care Credit, the leading dental financing company.
We DO NOT accept personal checks.
Should you have any questions regarding our financial policy, please discuss them with our front office staff prior to treatment. Thank you for investing in your dental health.
I have read and understand the financial policy. I authorize Renton Endodontics to keep my card on file for future payments and/or refunds. I would prefer Renton Endodontics to process any remaining balance by:
Process card on file for any remaining balance less than $50
Mail Statement
Call for Payment
Signature:
Date
HIPAA Information and Consent Form
The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been in our practice for years. This form is a “friendly” version. A more complete text is posted in the office.
What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services.
www.hhs.gov
We have adopted the following policies:
Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient’s condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI and other documents or information.
It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S. mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in normal performance of their duties.
You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
We agree to provide patients with access to their records in accordance with state and federal laws.
We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient.
You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.
Signature(Patient, Parent or Legal Guardian):
Date
If signed by patient representation, state relationship to patient: