New Patient Packet

Patient Information

SS#/SIN:

Date

Name

Birthdate

Home Phone

Address

City

State/Prov.

Zip/P.C.

Cell Phone

Select the appropriate:

Minor Single Married Divorced Widowed Separated

If student, Name of School/College

City

State/Prov.

Attending school

Full-time Part-time

Patient or Parent/Guardian's Employer

Work Phone

Business Address

City

State/Prov.

Zip/P.C.

Spouse or Parent/Guardian's Name

Employer

Work Phone

Whom may we thank for referring you?

Person to contact in case of emergency

Phone

Responsible Party

Name of Person Responsible for this Account

Relationship to Patient

Address

Home Phone

Cell Phone

Driver's License

Birthdate

Financial Institution

Employer

Work Phone

SS#/SIN

Is this person currently a patient in our office?

Yes No

For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.

Cash Personal Check VISA MasterCard Discover AMEX I wish to discuss the office's payment policy.

Insurance Information

Name of Insured

Relationship to Patient

Birthdate

SS#/SIN

Date Employed

Name of Employer

Union or Local #

Work Phone

Address of Employer

City

State/Prov.

Zip/P.C.

Insurance Company

Group #

Policy/ID #

Ins. Co. Address

City

State/Prov.

Zip/P.C.

How much is your deductible?

How much have you used?

Max. annual benefit

Do you have any additional insurance? (If yes, please complete the following information below:)

Yes No

Name of Insured

Relationship to Patient

Birthdate

SS#/SIN

Date Employed

Name of Employer

Union or Local #

Work Phone

Address of Employer

City

State/Prov.

Zip/P.C.

Insurance Company

Group #

Policy/ID #

Ins. Co. Address

City

State/Prov.

Zip/D.C.

How much is your deductible?

How much have you used?

Max. annual benefit

Patient Medical History

Physician

Office Phone

Date of Last Exam

1. Are you under medical treatment now?

Yes No

2. Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years?

Yes No

If yes, please explain.

3. Are you taking any medication(s) including non-prescription medicine?

Yes No

If yes, what medication(s) are you taking?

4. Have you ever taken Fen-Phen/Redux?

Yes No

5. Have you ever taken Fosamax, Boniva, Actonel or any cancer medications containing bisphosphonates?

Yes No

6. Do you use tobacco?

Yes No

7. Do you use controlled substances?

Yes No

8. Do you have or have you had any of the following?

High Blood Pressure

Yes No

Heart Disease

Yes No

Chest Pain

Yes No

Heart Attack

Yes No

Cardiac Pacemaker

Yes No

Easily Winded

Yes No

Rheumatic Fever

Yes No

Heart Murmur

Yes No

Stroke

Yes No

Swollen Ankles

Yes No

Angina

Yes No

Hay Fever/Allergies

Yes No

Fainting/Seizures

Yes No

Frequently Tired

Yes No

Tubercolosis

Yes No

Asthma

Yes No

Anemia

Yes No

Radiation Therapy

Yes No

Low Blood Pressure

Yes No

Emphysema

Yes No

Glaucoma

Yes No

Epilepsy/Convulsions

Yes No

Cancer

Yes No

Recent Weight Loss

Yes No

Leukemia

Yes No

Arthritis

Yes No

Liver Disease

Yes No

Diabetes

Yes No

Joint Replacement or Implant

Yes No

Heart Trouble

Yes No

Kidney Diseases

Yes No

Hepatitis/Jaundice

Yes No

Respiratory Problems

Yes No

AIDS or HIV Infection

Yes No

Sexually Transmitted Disease

Yes No

Mitral Valve Prolapse

Yes No

Thyroid Problem

Yes No

Stomach Troubles/Ulcers

Yes No

Acid Reflux

Yes No

Osteoporosis

Yes No

Other

9. Are you wearing contact lenses?

Yes No

10. Are you allergic to or have you had any reactions to the following?

Local Anesthetics (e.g. Novocain)

Yes No

Penicillin or any other Antibiotics

Yes No

Sulfa Drugs

Yes No

Barbiturates

Yes No

Sedatives

Yes No

Iodine

Yes No

Aspirin

Yes No

Any metals (e.g. nickel, mercury, etc.)

Yes No

Latex Rubber

Yes No

Other

11: Do you have a persistent cough or throat clearing not associated with a known illness (lasting more than 3 weeks)?

Yes No

12. Women Only

Are you pregnant or think you may be pregnant?

Yes No

Are you nursing?

Yes No

Are you taking oral contraceptives?

Yes No

Patient Dental History

Name of Previous Dentist and Location

Date of Last Exam

1. Do your gums bleed while brushing or flossing?

Yes No

2. Are your teeth sensitive to hot or cold liquids/foods?

Yes No

3. Are your teeth sensitive to sweet or sour liquids/foods?

Yes No

4. Do you feel pain to any of your teeth?

Yes No

5. Do you have any sores or lumps in or near your mouth?

Yes No

6. Have you had any head, neck, or jaw injuries?

Yes No

7. Have you ever experienced any of the following problems in your jaw?

Clicking

Yes No

Pain (joint, ear, side of face)

Yes No

Difficulty in opening or closing?

Yes No

Difficulty in chewing?

Yes No

8. Do you have frequent headaches?

Yes No

9. Do you clench or grind your teeth?

Yes No

10. Do you bite your lips of cheeks frequently?

Yes No

11. Have you ever had any difficult extractions in the past?

Yes No

12. Have you ever had any prolonged bleeding following extractions?

Yes No

13. Have you had any orthodontic treatment?

Yes No

14. Do you wear dentures or partials?

Yes No

If yes, date of placement

15. Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

Yes No

16. Do you like your smile?

Yes No

Authorization and Release

I certify that I have read and understand the information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.

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 (or parent/guardian if minor)

Date

HIPAA Compliance Patient Consent Form

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 and 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 a revocation will not be retroactive.

By signing this form, I understand:

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:

This consent was signed by:

Date

Witness

Date

Oral Screening Consent Form

Our Practice (DBM Dental) continually looks for advances to ensure that we are providing the optimum level of oral health care to our patients. We are concerned about oral cancer and look for it in every patient.

One American dies every hour from oral cancer. Late detection of oral cancer is the primary cause that both the incidence and mortality rates of oral cancer continue to increase. As with most cancers, age is the primary risk factor for oral cancer. Tobacco and Alcohol use are other major predisposing risk factors, but more than 25% of oral cancer victims have no such lifestyle with using these risk factors, Oral cancer risk factors are as follows:

Increased risk: patients age 18-39 - sexually active patients (HPV)
High risk: patients age 40 and older; tobacco uses (any age, any type within 10 years)
Highest risk: patients age 40 and older with lifestyles consisting of using tobacco and/or alcohol

We have recently incorporated Veloscope into our oral screening exam. We find that using Veloscope during the oral cancer examination improves our ability to identify suspicious areas at their earliest stages. Veloscope is similar to early detection procedures for other cancers such as mammography, Pap Smear, and PSA.

This advanced examination is recognized by the American Dental Association, however, this exam might not be covered by your dental insurance. The fee for this advanced examination is $20.00.

Yes: I authorize the clinician to perform oral cancer detection with the use of the Veloscope instrument and accept financial responsibility for this examination.

Signature

Date

No: I would not prefer to have the Veloscope used at this time. I do however understand the benefits of using this during my dental examination.

Signature

Date

Current Medications List

Name

Date

Emergency Contact Name/Phone

Prescription Medications

Add new row

Allergies

Additional Info

COVID-19 (Coronavirus) Disclosed and Informed Consent

I affirm that DBM Dental, Ltd, Dr. Michael Perry and team members operating within this practice have offered me the opportunity to reschedule my dental treatment to an alternative date. I also affirm that I have freely elected to proceed with my essential or non-essential dental procedure at this time.

I have been made aware by the Practice that while the Practice has implemented several new safety measures to prevent or reduce the spread of the COVID-19 virus, they cannot make any guarantees. The staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since they are a place of public accommodation, other persons (including other patients) could be infected, with or without their knowledge. Therefore, I fully understand that proceeding with the treatment today could potentially have exposure-risk associated with COVID-19.

I understand that acquiring COVID-19 can lead to severe symptoms such as fever, chest pain, shortness of breath and respiratory complications and other associated symptoms. Advanced COVID-19 disease can also lead to prolonged hospitalization, intensive care admission, mechanical ventilation, or even possible death.

I also agree that neither I nor my family members/individuals with whom I currently reside with have been exposed to or are experiencing any of the following symptoms in the past 14-21 days.

Shortness of breath
Chest pain
Fever
Runny nose, loss of smell or taste
Sore throat
Fatigue and body aches
Other symptoms associated with COVID-19
Confirmed or suspected COVID-19 (Coronavirus) Infection

I am consenting to this procedure with full understanding and disclosure of such risks and alternatives. I am consenting to a charge per visit of $10.00 for the office sterilization fee with these new procedures until further notice.

If the patient is under 18, a parent or guardian must sign below to consent to the procedure with full understanding and disclosure of such risks and alternatives.

Patient Name

Guardian Name

Patient/Guardian Signature

Date

Patient Screening Form

Patient Name

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

Yes No

Are you/they having shortness of breath or other difficulties breathing?

Yes No

Do you/they have a cough?

Yes No

Any other flu-like symptoms such as gastrointestinal upset, headache or fatigue?

Yes No

Have you/they experienced recent loss of taste or smell?

Yes No

Are you/they in contact with any confirmed COVID-19 positive patients? Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Yes No

Is your/their age over 60?

Yes No

Do you/they have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders?

Yes No

Have you/they traveled in the past 14 days?

Yes No

Positive responses to any of these would likely indicate a deeper discussion with the dentist before proceeding with elective dental treatment.

For testing, see the list of State and Territorial Health Department Websites for your specific area's information.

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