Medical Records Update

Name:

Confidential Patient Information

Last Name:

First Name:

Initial:

Preferred Name:

Are your address and phone number still the same as previously provided on your most recent medical history?

Yes No

Street Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Updated Email:

Medical History

Physician's Name:

Date of Last Physical:

Are you allergic to:

Penicillin

Codeine

Local Anesthetics

Latex

Do you have any drug allergies or have had an adverse reaction to any medications?

Yes No

If so, what?

Have you responded adversely to medical or dental treatment?

Please list ALL medications, pills, or drugs you are taking on the sheet provided (next page).

Are you taking any of the following medications?

Premedication before dental treatment

Antacids

Tagamet

Herbal Supplements

Warfarin or Coumadin

Other

If other, please specify:

Have you been treated with Bisphosphonate drugs?

Fosamax

Boniva

Actonel

For how long?

Are you under the care of a physician?

Yes No

For what conditions?

Have you had any major operations?

Yes No

If yes, what?

Do you suffer from any disability?

Yes No

If yes, what?

Do you smoke?

Yes No

If patient is a child, what is his/her weight?

(Women)

Do you suspect you are pregnant?

Yes No

Are you nursing?

Yes No

Are you taking oral conceptives?

Yes No

Have you ever had any of the following? (Please select Yes or No)

Artificial Heart Valve

Yes No

Artificial Joints/Hips/Knee

Yes No

Hepatitis

Yes No

Heart Murmur

Yes No

Asthma

Yes No

Liver Disease

Yes No

Leaky Heart Valve

Yes No

Shortness of Breath

Yes No

Venereal Disease

Yes No

Mitral Valve Prolapse

Yes No

Fainting or Dizziness

Yes No

Recent Weight Loss

Yes No

Heart Attack

Yes No

Stroke

Yes No

Tubercolosis

Yes No

Heart Pacemaker

Yes No

Diabetes

Yes No

Psychiatric Care

Yes No

Heart Surgery

Yes No

Kidney Trouble

Yes No

Ulcers

Yes No

Chest Pain

Yes No

Chemotherapy/Radiation

Yes No

Epilepsy or Seizure

Yes No

Heart Stents

Yes No

Rheumatic Fever

Yes No

HIV Positive

Yes No

High Blood Pressure

Yes No

Irregular Heartbeat

Yes No

AIDS

Yes No

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 person completing this form

Date:

Relationship (if other than patient)

List of Medications

Add new row

HIPAA Omnibus Rule

Patient Acknowledgement of Receipt of Notice of Privacy Practices and Consent/Limited Authorization & Release Form

You may refuse to sign this acknowledgement & authorization. In refusing, we may not be allowed to process your insurance claims.

Date:

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.

Name

Signature

Legal Representative

Description on Authority

Your comments regarding Acknowledgement and Consents:

How do you want to be addressed when summoned from the reception area:

First Name Only Proper Sir Name Other

If other, please provide details.

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION

(This includes step parents, grandparents, and any care takers who can have access to this patient's records):

Add new row

I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA

Cell Phone Confirmation

Home Phone Confirmation

Work Phone Confirmation

Text Message to my Cell Phone

Email Confirmation

Any of the Above

I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA

Cell Phone Confirmation

Home Phone Confirmation

Work Phone Confirmation

Text Message to my Cell Phone

Email Confirmation

Any of the Above

I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on behalf of this Healthcare Facility via:

Phone Message

Text Message

Any of the Above

None of the Above (opt out)

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

Información Confidencial del Paciente

Fecha:

Apellido:

Nombre:

Inicial:

Nombre que Prefiere:

¿Su Dirección y Teléfono se mantienen igual que en la información que ofreció en su hisoria médica más reciente?

Si No

Dirección

Ciudad

Estado

Código

Número Tel Casa

Número Tel Celular

Historia Médica

Médico General

Fecha del último Examen Físico

¿Es alérgico(a) a?:

Penicilina

Codeina

Anestesia Local

Látex

¿Tiene alguna alergia a otro medicamento o ha tenido alguna reacción adversa a medicamentos?

Si No

¿A cuál/cuáles?

¿Alguna vez ha tenido reacción a algún Tratamiento Dental ?

Por favor escriba en la tabla TODOS los medicamentos, pastillas o drogas que está tomando (en la próxima página).

¿Esta usando alguno de los siguientes?

Premedicación antes de tratamiento dental

Antiácidos

Tagamet

Suplementos Naturales

Warfarin o Coumadin

Otro

En otro caso, por favor especifica

¿Alguna vez ha usado Bisfosfonatos?

Fosamax

Boniva

Actonel

¿Por cuánto tiempo?

¿Está bajo cuidado médico actualmente?

Si No

¿Para que condición?

¿Ha tenido alguna operación?

Si No

De qué?

¿Sufre alguna incapacidad?

Si No

¿Cuál?

¿Fuma?

Si No

¿Si el paciente es un niño(a), ¿Cuánto pesa?

Mujer

¿Está Embarazada?

Si No

¿Está lactando?

Si No

¿Está tomando anticonceptivos?

Si No

¿Alguna vez ha padecido de lo siguiente? (Marque Si o No)

Válvula Cardiaca Artificial

Si No

Articulaciones Artificiales

Si No

Hepatitis

Si No

Soplo en el corazón

Si No

Asma

Si No

Enfermedad Hepática

Si No

Válvula cardiaca permeable

Si No

Falta de Aliento

Si No

Enfermedad Venérea

Si No

Prolapso de la Válvula Mitral

Si No

Mareos o Desmayos

Si No

Pérdida de peso reciente

Si No

Infarto Cardiaco

Si No

Accidente Cerebrovascular (Stroke)

Si No

Tuberculosis

Si No

Marca Pasos

Si No

Diabetes

Si No

Atención Psiquiatrica

Si No

Cirugía de Corazón

Si No

Problema Renal

Si No

Ulceras

Si No

Dolor de Pecho

Si No

Quimioterapia/Radiación

Si No

Epilepsia/Convulsiones

Si No

Cánula Cardiaca (Stent)

Si No

Fiebre Reumática

Si No

HIV Positivo

Si No

Presión Alta

Si No

Latidos Irregulares

Si No

SIDA

Si No

DESCARGO DE RESPONSABILIDAD: Al escribir su nombre a continuación, está firmando esta solicitud electrónicamente. Acepta que su firma electrónica es el equivalente legal de su firma manual en esta aplicación.

Nombre y firma de la persona que completó este Formulario

Fecha:

Relación con el paciente

Lista de Medicamentos

Add new row

HIPAA Omnibus Rule

Patient Acknowledgement of Receipt of Notice of Privacy Practices and Consent/ Limited Authorization & Release Form

You may refuse to sign this acknowledgement & authorization. In refusing, we may not be allowed to process your insurance claims.

Date:

Print your name

Sign your name

Legal Representative

Description of Authority

Your comments regarding Acknowledgements or Consents:

How do you want to be addressed when summoned from the reception area:

First Name Only Proper Sir Name Other

If other, please provide details.

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION

(This includes step parents, grandparents, and any care takers who can have access to this patient's records):

Add new row

I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA

Cell Phone Confirmation

Home Phone Confirmation

Work Phone Confirmation

Text Message to my Cell Phone

Email Confirmation

Any of the Above

I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA

Cell Phone Confirmation

Home Phone Confirmation

Work Phone Confirmation

Text Message to my Cell Phone

Email Confirmation

Any of the Above

I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on behalf of this Healthcare Facility via:

Phone Message

Text Message

Any of the Above

None of the Above (opt out)

Your information will be encrypted.