Adult Patient Information

Please correct the errors described below.

Primary Insurance Information:

Secondary Insurance Information:

I understand and agree that, (regardless of my insurance status) I am responsible for the balance on my account for any professional services rendered. I have read all of the information on this form and have completed the above questions. I certify this information is correct and I will notify you of any changes in my health status or the above information

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

Total Wellness Screening

At Park Dental Wellness, we are devoted to helping you establish your teeth and bite in optimum health, for a lifetime. We are equally committed to your whole health.

Please select the answer that best describes you.

Periodontal Pathogens (harmful oral bacteria): Studies show that harmful bacteria in the mouth are a primary cause of tooth decay, bleeding gums, periodontal disease, tooth loss, and body-wide inflammation.

Nutrition: Studies show that whole fruits and veggies strengthen bone, gums, and teeth.

Studies show that refined foods containing sugar, flour, and white rice weaken bone, gums, and teeth. This includes sodas/diet sodas, energy drinks, juices, breads, fried foods, and processed snacks (chips, candy).

Physical Activity: Studies show that physical activity is critical to total wellness and that physical inactivity is “the biggest public health issue of the 21st century”

Toxins Exposure Studies show that toxins, such as tobacco and mercury overexposure (fish), are significant risk facts for body-wide inflammation.

Health History Form

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

If you are completing this form for another person, what is your relationship to that person?

Do you have any of the following diseases or problems: (Check DK if you Don’t Know the answer to the the question)

Dental Information

For the following questions, please mark your responses to the following questions. (Check DK if you Don’t Know the answer to the the question)

Medical Information

Please mark your response to indicate if you have or have not had any of the following diseases or problems. (Check DK if you Don’t Know the answer to the the question)

WOMEN ONLY Are you:

Allergies. Are you allergic to or have you had a reaction to: To all yes responses, specify type of reaction below.

Please mark your response to indicate if you have or have not had any of the following diseases or problems. (Check DK if you Don’t Know the answer to the the question)

Congenital heart disease (CHD)

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

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

Patient Acknowledgement and Consent Form

Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accounting Act of 1996 (HIPPA) requires that this office comply with certain rules regarding the privacy of your information that we have collected and will collect in the future.

To comply with one of HIPPA’s requirements we have copies of our Notice of Privacy Practices in the office for your review. This Notice of Privacy Practices contains the information that HIPPA requires us to disclose regarding our privacy practices.

Existing Michigan law requires us to first obtain your written consent prior to disclosing any of your information except for your disclosures in connections with: a defense to a claim challenging our professional competence; a review entity’s functions; a claim for payment of fees; a third party payer’s examination of our records; a court order as part of a criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse/neglect investigation. From time to time it may be necessary for us to make disclosures of your information in connection with our treatment. For example, we may make a referral to or consult with another dentist or other health care professional, provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment.

Patient Acknowledgement

I acknowledge that I have today received and/or had access to a copy of the Notice of Privacy Practices. I consent to your disclosure of my information, which you deem necessary in connection with my treatment. I understand that such disclosures may not be of the type listed above.

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

Authorization

I hereby certify that I have read and understood the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect/inaccurate information has the potential of being hazardous to my health. If I ever have a change in my health I will inform the office at my next dental appointment without fail.

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

I also authorize Park Dental Center, Linda M Park, to use my likeness in a photograph and/or x-rays in all publications including but not limited to printed and digital publications and advertisements. I acknowledge that I will receive no compensation for the use of my likeness.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on the behalf of my dependents (if any) and/or anyone covered on my insurance. I understand that I will be charged .58% interest month (7% annually) on balances over 90 days old.

I have been informed and agree that I will be charged a $40.00 fee for appointments cancelled with less than 48 hours’ notice.

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

Adult Airway Questionnaire/ Epworth Sleepiness Scale

Please fill out this form as accurately and honestly as possible. Dr. Park understands the importance of breathing and the form and function of the upper airway that affect your total health and wellness. It is documented that the mildest form of Sleep Disorder Breathing, and or SNORING can impair neurobehavioral development. Based on the wellness model, our team will evaluate your body as a whole, treat the underlying causes, restore your body’s optimal breathing, sleep habits, improve your overall health and elevate your quality of life.

Please use the scale to determine your level of sleepiness.

  • 0= no chance of dozing
  • 1= slight chance of dozing
  • 2=moderate chance of dozing or sleeping
  • 3= high chance of dozing or sleeping

Please answer the following questions:

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

Linda Park, D.D.S., 4300 East Court St, Burton, MI 48509, Phone: 810-742-5140,Fax: 810-742-6650 Email: parkdentalfrontdesk@gmail.com

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