Health History

Thank you for choosing our practice for your dental needs. Please take a moment to enter or update your information to help us ensure the quality of your care is excellent.

Patient Name:

Date:

SSN:

Gender:

Male Female

Family Status:

Married Single Child Other

If Other, please specify

Date of Birth:

E-mail:

Home Phone:

Cell:

Address:

City:

State:

Zip:

Patient Employer

Emergency Contacts:

Add emergency contact

Who referred you to Wooster Family Dental?

Expectations

We respect our patients’ time. Therefore, we do everything we can do to work efficiently on treatment. We request the same from you. Please be on time and give us a 48 hour notice if you need to adjust any appointment. All broken appointments will result in a $65.00 fee.

Please initial:

We are a zero-balance office. If there is an investment in your health, what method of payment would you use? Please select:

Cash

Credit

Check

Financing (Care Credit)

HSA

Please initial here if you do not have Dental Insurance/Self-Pay Status:

Dental Insurance Information

(Please provide a copy of your Dental Insurance card)

Add file

Please upload a file

Name of Policy Holder:

Birth Date:

Member ID/SSN #:

Group #:

Policy Holder’s Employers Name:

Patient’s Relationship to Policy Holder:

Self Spouse Parent Other

If Other, please specify:

Insurance Company:

Insured’s SSN:

Insurance Co. Mailing Address:

City:

State:

Zip:

VETERAN STATUS: Are you now or have you ever served in the military?

Yes No

Health Information

1. Are you taking prescription(s)/over-the-counter or supplement drugs?

Yes No

If yes, please list medications below:

Please upload an image of your medication list, or any additional health or personal information

Add file

Please upload a file

2. Do you have any allergies?

Yes No

If yes, please select all that apply:

Penicillin

Antibiotics

Anesthetics

Aspirin

Foods

Latex

Resins

Other

If Other, please specify:

3. Do you require antibiotics before dental treatment?

Yes No

If yes, what premedication (antibiotic) have you been prescribed & who is your prescriber?

4. Women: Are you pregnant?

Yes No

Trying to get pregnant?

Yes No

Are you taking oral contraceptives?

Yes No

5. Symptoms or conditions below that you currently HAVE or HAVE HAD in the past year(s): (Please list the Year Diagnosed (DX))

Alcohol Abuse:

Yes No

Year Dx:

Drug Abuse:

Yes No

Year Dx:

Osteoarthritis:

Yes No

Year Dx:

Anemia:

Yes No

Year Dx:

Liver Problems

Yes No

Year Dx:

Tobacco Habit:

Yes No

Year Dx:

Psychiatric Care

Yes No

Year Dx:

Back Problems:

Yes No

Year Dx:

Artificial Joints:

Yes No

Year Dx:

High Blood Pressure:

Yes No

Year Dx:

Tuberculosis:

Yes No

Year Dx:

Heart Murmur:

Yes No

Year Dx:

Heart Ailments/Heart Attack:

Yes No

Year Dx:

Mitral Valve Prolapse:

Yes No

Year Dx:

Rheumatic Fever:

Yes No

Year Dx:

Glaucoma:

Yes No

Year Dx:

Hepatitis A, B, C:

Yes No

Year Dx:

Shingles:

Yes No

Year Dx:

Kidney Disease:

Yes No

Year Dx:

Ulcers/Colitis:

Yes No

Year Dx:

Osteoporosis:

Yes No

Year Dx:

Stroke:

Yes No

Year Dx:

If Yes, Please Specify

Low Blood Pressure:

Yes No

Year Dx:

Diabetes (I/II/III):

Yes No

Year Dx:

Epilepsy

Yes No

Year Dx:

Specialist Name:

Allergies to Medicine(s) :

Yes No

Year Dx:

Sinus problems:

Yes No

Year Dx:

Thyroid Disease:

Yes No

Year Dx:

Asthma:

Yes No

Year Dx:

AIDS/HIV:

Yes No

Year Dx:

STDs:

Yes No

Year Dx:

If Yes, Please Specify

Rheumatoid Arthritis

Yes No

Year Dx:

Specialist Name:

6. Do you have any other health conditions?

Yes No

If yes, please explain:

7. Are you currently Taking bisphosphonate / Fosamax?

Yes No

8. Do you have history of cancer/chemotherapy/radiation?

Yes No

Are you currently receiving treatment?

Yes No

If Yes, Please Specify

9. Have you ever been a recipient of an organ transplant?

Yes No

If yes, please explain:

10. Primary Care Physician:

Phone Number:

11. Specialist Physician:

Phone Number:

Consent for Services

As a condition of treatment by this office, financial arrangements must be made in advance.The practice depends upon reimbursement from patients for the costs incurred in their care.Financial responsibility on the part of each patient must be determined before treatment.

All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash or credit card at the time services are performed unless other arrangements are made.

Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient’s insurance forms or assist in making collections from insurance companies and will credit any collections to the patient’s accounts. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days unless previously written financial arrangements are satisfied.

I understand that any fee estimate for this dental care can only be extended for a period of 90days from the date of the patient explanation.

In consideration for the professional services rendered to me by this practice, I agree to pay the charges for the services at the time of treatment. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant permission to you or your assignee to telephone me to discuss this statement or mistreatment.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

I have read the above conditions of treatment and payment and agree to their content.

Signature:

Date:

Relationship to Patient:

HIPAA Acknowledgement

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such revocation will not be retroactive.

By signing this form, I understand that:

Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
The practice reserves the right to change the privacy policy as allowed by law.
The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
The practice may condition receipt of treatment upon execution of this consent.

May we phone, email, or send a text to you to confirm appointments?

Yes No

May we leave a message on your answering machine at home or on your cell phone?

Yes No

May we discuss your medical condition with any member of your family?

Yes No

If YES, please name the members allowed:

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Signature of patient, parent, or guardian (responsible party):

Date:

Missed Appointment Agreement

Trying to accommodate every patient’s individual needs and work schedules can be difficult; we always try to do our best. We work very hard to stay on schedule so that our valuable patients will not spend time in our reception area for an appointment.

A scheduled appointment is a commitment of time between you and our practice. We have reserved that time just for you. When appointments are missed or cancelled, that time is permanently lost.

We ask when you schedule an appointment that you make every effort to keep that commitment. We understand that personal emergencies sometimes occur, and we always take that into consideration when receiving a last-minute cancellation.

If you find that you cannot keep your scheduled appointment, we ask that you provide a minimum notice of 48 hours. You can even leave a message or text us over the weekend. This allows us to offer this time to another patient in need. Failure to do so will result in a $65.00 missed appointment fee.

From the date of this agreement, each patient is entitled to three missed appointments in the life of the relationship with the practice. After three missed appointments, our office will visit with you regarding our relationship and determine if your dental needs might be better served by another provider. We may alternatively determine that it will be necessary for you to call and ask about same day availability on a day that you are able to make time for us and/or prepay for the services that will be rendered at your ensuing appointments.

If you have any questions, please do not hesitate to ask. We sincerely appreciate your understanding and cooperation with this matter.

Patient signature

Date:

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