Mary Jean A. Oropesa, DDS, PLLC

Welcome to our Practice

Thank you for choosing the office of Dr. Mary Jean A. Oropesa! Our goal is to provide you with the best possible care, at the same time make your visit as pleasant and comfortable as possible. To help you meet all your dental healthcare needs, please fill out this form completely. This information is important for our dental records and your health, and is of course, confidential. Please feel free to contact us if you have any questions or need assistance - we will be happy to help.

Patient's Full Name

Preferred Name

Title

Birthdate

SS #

Previous Visit

Best time to call

Email address

Home Phone No.

Work Phone No.

Cell Phone No.

Address 1

Address 2

City

State

Zip

The following is for

the patient the person responsible for payment both not applicable

Employer Name

Phone No.

Employer Address

City

State

Zip

Whom may we thank for referring you to our practice?

In an emergency who should be notified? Please enter Name and Phone number below

Name

Phone No.

Responsible Party Information

This only need to be filled out if the insurance subscriber is other than the patient, or if the patient is under 18.

The following is for

the patient's spouse the person responsible for payment both neither-not applicable

Title

Birthdate

SS #

DL No.

Email address

Best time to call

Phone No.

Work Phone No.

Cell Phone No.

Home Phone No.

Address 1

Address 2

City

State

Zip

Add new row

Insurance Authorization

I authorize my insurance company to pay the dentist all insurance benefits rendered.

I authorize the use of this electronic signature on all insurance submissions.

I authorize the dentist to release all information necessary to secure the payment of benefits.

I understand that I am financially responsible for all charges whether or not paid by insurance.

Medical History

Indicate which of the following conditions you have or have had. By checking the box it will indicate a "YES" response, leaving blank will indicate a "NO" response.

Ever been hospitalized (illness or injury)

Taking medication for weight control (ie fen-phen)

Subject to frequent headaches

FEMALE: Taking birth control pills

Presently being treated for any other illnesses

Taking dietary supplements

A smoker or smoked previously

FEMALE: Pregnant

If any conditions or alerts selected above needs further clarification, please describe below:

Do you take antibiotic premedication for your dental visits? If yes, please explain.

What is your estimate of your general health?

Excellent

Good

Fair

Poor

Name of your physician and your most recent physical exam

Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment.

List all medications, drugs, pills or herbal remedies, including regular dosages of aspirin.

By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and had responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes.

Dental Information

How would you rate the condition of your mouth?

Excellent Good Fair Poor

Previous Dentist name and how long have you been a patient there

Date of most recent dental exam:

Date of most recent dental x-rays

I routinely see my dentist every

3 mo.

4 mo.

6 mo.

12 mo.

Not routinely

What is your immediate concern?

Are you fearful of dental treatment? How fearful, on a scale of 1 (least) to 10 (most)

Personal History, Check all that apply

Had an unfavorable dental experience

Had trouble getting numb

Had/have braces, orthodontic treatment

Had any teeth removed

Had complications from past dental treatment

Had any reactions to local anesthetic

Had your bite adjusted

Smile Characteristics, Check all that apply

Is there anything about the appearance of your teeth that you would like to change?

Have you ever whitened (bleached) your teeth?

Have you felt uncomfortable or self conscious about the appearance of your teeth?

Have you been disappointed with the appearance of previous dental work?

Bite and Jaw Joint, Check all that apply

You have problems with your jaw joint

You have problems chewing

Your teeth changed in the last 5 years, become shorter, thinner, or worn

Your teeth are crowding or developing spaces

You chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits

You clench your teeth in the daytime or make them sore

You have problems with sleep or wake up with an awareness of your teeth

You wear or have worn a bite appliance

Tooth structure, Check all that apply

Cavities within past 3 years

The amount of saliva in your mouth seems too little or you have difficulty swallowing any food

You notice or have holes (i.e. pitting, crates) on the biting surface of your teeth

Any teeth sensitive to hot, cold, biting, sweets, or avoid brushing any part of your mouth

Grooves or notches on your teeth, chipped teeth, or had a toothache or cracked filling

Food gets caught between any teeth

Gum and Bone, Check all that apply

Gums bleed when brushing or flossing

Treated for gum disease or were told you have lost bone around your teeth

Noticed an unpleasant taste or odor in your mouth

History of periodontal disease in your family

Experienced gum recession

Had any teeth become loose on their own (without injury), or have difficulty eating an apple

Experienced a burning sensation in your mouth

Do you wear Dentures? If yes, how many sets and how long have you had it?

If any of the checked boxes need further explanation, please describe

Epworth Sleepiness Scale

How likely are you to doze off or fall asleep in the situations described below, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven't done some of these things recently try to work out how they have affected you.

Use the following scale to choose the most appropriate number for each situation:

0 = would NEVER doze off
1 = SLIGHT chance of dozing
2 = MODERATE chance of dozing
3 = HIGH chance of dozing

TOTAL SCORE

0 - 10 NORMAL RANGE 10 - 12 BORDERLINE 12 - 24 ABNORMAL

Consent for Treatment

I hereby authorize Dr. Oropesa or designated staff to take X-rays, study models, photographs and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of the patient named above for their dental needs. Upon such diagnosis,

I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives and other medications as necessary. I fully understand that using anesthetic agents embodies certain risks.

I understand that I can ask about any possible complications. I authorize the release of required information including the diagnosis and the records of pertinent treatment or examination rendered to myself or my dependent during the period of such dental care to third party payers and /or other healthcare practitioners.

By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Administration Form

Consent for Services and Financial Policy

To be able to provide the quality of care and service to our valued patients, and to keep the cost of dentistry down, 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 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 account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1.5% 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 six months from the date of the patient examination.

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, or within five (5) days of billing if credit is extended. I further agree that the charges for services shall be as billed unless objected to, by me, in writing, within the time payment is due. 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 my permission to you or your assignee, to telephone me to discuss this statement or my treatment.

Checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Administration Form.

HIPAA Acknowledgement

I understand that I may inspect or copy the protected health information described by this authorization.

I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form.

I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality,

By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the HIPAA Disclosure Form.

In addition to the allowable disclosures described in the Notice of Privacy Practices, I hereby authorize disclosure of my protected health care information to the person indicated below:

ANY IMMEDIATE FAMILY MEMBER

Yes No

SPOUSE

Yes No

OTHER ( Please specify)

By checking this box, I understand the above information and agree with its contents, and this will serve as my electronic signature for the Administration Form.

Print your name if signed on behalf of the patient and relationship:

Date

Consent for Internet Communications

I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.

I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.

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 information above regarding the secured uploading of patient information to the web site for the dental practice, and grant the dental practice permission to securely upload my patient information to the web site.

Signature

Date

Your information will be encrypted.