New Patient Packet (English)

Confidential Patient Information

Date:

Home Phone

Cell Phone:

Email address

Last Name:

First Name:

Initial:

Preferred Name:

Street Address

City

State

Zip

Sex:

Male Female

Birth Date:

Age:

Social Security:

Status:

Single Married Other

Employed by:

Occupation:

Business Address:

Business Phone:

Spouse Name:

Employed by:

Occupation:

Business Address:

Business Phone:

Who is responsible for this account?

Relationship to Patient:

Spouse Social Security:

Birth Date:

Name of Dental Insurance Company:

Group Number:

In case of emergency, who should be notified?

Phone:

Whom may we thank for referring you?

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 ever responded adversely to any medical or dental treatment?

Please list ALL medications, pills, or drugs you are taking on the 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 ever been treated with Bisphosphonate drugs?

Fosamax

Boniva

Actonel

For how long?

Are you under a 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 contraceptives?

Yes No

Have you ever had any of the following? (Please choose 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

Veneral 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 form electronically. You agree 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

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Dental Health History

Are you apprehensive about dental treatment?

Yes No

Have you ever had braces?

Yes No

Do you gag easily?

Yes No

If yes, when?

Does food catch between your teeth?

Yes No

Do you have any gum recession?

Yes No

Do you have difficulty in chewing your food?

Yes No

Have you ever had teeth removed?

Yes No

Do your gums bleed easily?

Yes No

If so, for what reason?

Loose Teeth

Cavities

Trauma

Broken Teeth

Do your gums feel swollen or tender?

Yes No

Are you happy with your smile?

Yes No

Are your teeth sensitive to any of the following:

Hot foods or liquids

Yes No

Do you prefer to save your teeth?

Yes No

Cold foods or liquids

Yes No

Do you wear dentures?

Yes No

Sweets

Yes No

If yes, do you experience, any of the following:

Loose dentures

Lack of taste

Difficulty chewing

Lack of sensation

Do you have any of the following symptoms:

Bad Breath

Yes No

Does your jaw make noise?

Yes No

Loose Teeth

Yes No

Do you clench or grind your teeth?

Yes No

Pain on biting

Yes No

Does it hurt when you chew or open wide?

Yes No

Dry mouth

Yes No

Do you have earaches or pain in front of the ears?

Yes No

Have you ever had treatment for gum disease?

Yes No

Do you have any jaw symptoms or headaches upon waking up in the morning?

Yes No

If yes, have you had:

Scaling/root planing (deep cleaning)

Yes No

Have you had a blow to the jaw (trauma)?

Yes No

If yes, when?

Have you ever noticed slow-healing sores in or about your mouth?

Yes No

Periodontal surgery?

Yes No

Is there anything else we should know about?

If yes, when?

How often do you get your teeth cleaned?

How often do you brush?

How often do you floss?

Do you use any other oral hygiene aids?

Yes No

If yes, please list:

The above information is accurate and complete to the best of my knowledge. I grant the right to the dentist to release health information obtained from me, and information about my dental treatment to third party payers, and/or other health practitioners.

DISCLAIMER: By typing your name below, you are signing this form electronically. You agree 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)

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 RELEASED SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR/FACILITIES IN THE FUTURE.

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.

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 to 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 Cellphone

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.

Written Financial Policy

Thank you for choosing World Dental. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

Payment Options:

You can choose from:

- Cash, Check, Visa, Master Card, or Discover Card

We offer a 5% courtesy accounting adjustment to patients who pay for their treatment in full with cash or check prior to or on the date treatment starts, for plans of $1000 or more. Not eligible with insurance, if you choose to pay in full and allow insurance to pay you then we can accommodate you with this offer.

- No INTEREST (See Note 1) Payment Plans (See Note 2) from Care Credit

Allow you to pay over time with NO INTEREST (See Note 1)
Convenient, low monthly payment plans (See Note 2) also available
No annual fees or pre-payment penalties

Please note:

For plans requiring multiple appointments, alternative payment arrangements may be provided. For larger, more comprehensive treatment plans of $500 or more, a $50 deposit is required to secure your initial treatment appointment.

For patients with dental insurance, we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment. (See Note 3)

A fee of $25 is charged for patients who miss or cancel without 24-hour notice more than one time.
Our office charges $45 for returned checks.

If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.

Patient, Parent or Guardian Signature

Date

Patient Name

Notes:

Note 1: If paid within the promotional period. Otherwise, interest assessed from purchase date. Minimum monthly payment required.

Note 2: Subject to credit approval

Note 3: However, if we do not receive payment from your insurance carrier within 90 days, you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.

Insurance Disclaimer

As a courtesy, Dr. Marian Lauzan will submit my insurance claim for me. Should my insurance plan deny, pay at an alternate benefit, or otherwise not cover any treatment rendered, then I (indicate name on the space provided below this paragraph) am responsible for the remaining balance. The insurance company does not guarantee any insurance claim payments until they receive the actual claim. Calling, verifying, and receiving eligibility and percentages do not guarantee payment, these only provide an estimate of what my insurance will pay.

Name:

I do not have any dental insurance that will be helping me with services rended.

Signature

Date

Consent for Release of Dental Records

I (provide patient name below this paragraph), consent to Dr. Lauzan and World Dental Associates, PA, to use my name, x-rays, photographs, and models for the purpose of case presentation and marketing. Case presentations would include, but would not be limited to, continuing education seminars, publications, and study clubs. Marketing would include, but would not be limited to, posting on the office website, newspaper/magazine ads, postcards, internet marketing, television commercials, infomercials, and TV shows.

Name:

Signature

Date

Medicare Disclaimer

Initials

This office has opted-out of Medicare. You, the Medicare beneficiary, or your legal representative, accepts full responsibility for all payment due for services in this office.

Initials

You or your legal representative understands that Medicare limits do not apply to what the doctor may charge for services rendered.

Initials

You or your legal representative agrees not to submit a claim to Medicare or to ask this office to submit a claim on your behalf.

Initials

You or your legal representative enters into this contract with the knowledge that you have the right to obtain Medicare-covered items and services from physicians and practitioners who have opted-out of Medicare.

Initials

You or your legal representative understands that Medigap plans and other supplemental plans may elect not to make payments for items and services not paid for by Medicare.

PLEASE SIGN AND DATE THAT YOU HAVE READ AND UNDERSTAND THE ABOVE INFORMATION. THANK YOU

Signature

Date

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