PATIENT INTAKE FORM

Moreno Valley Endodontics

Confidential Patient Information

First name

Last name

Gender:

Male Female

Date of birth

Social Security

Phone / Cell

Home

Work

Email address

Address

Apt

City

State

Zip

Occupation

Work Address

Preferred Method of Contact:

Cell Phone Home Phone Work Phone Email

Any family members seen by us?

Name of General Dentist / Referring Dentist

Phone

Name of your Medical Doctor

Medical / Kaiser

Phone

City

State

Zip

Dental Insurance Information

Primary Dental Plan Name

Phone

Who is the primary subscriber?

Member ID / Primary Social Security

Date of Birth

Secondary Dental Plan Name

Phone

Name of Insured

Relationship to Patient

Member ID / Social Security

Date of Birth

Medical History

Emergency contact name:

Relationship to patient

Phone

1. Are you having tooth pain or discomfort now?

Yes No

2. Have you been under the care of a medical doctor during the past two years? If yes, proceed to question 3. If no, move to question 4

Yes No

3. If you have been under the care of a doctor, what condition(s) was treated or is currently being treated?

Physician's Name & Number

4. Are you now taking any medications or drugs?

Yes No

If yes, what medications or drugs are you taking?

5. Have you had Covid-19 recently?

Yes No

Have you been in close contact with somone with Covid-19?

Yes No

6. Do you have or have you ever had any of the following diseases or problems?

Active Tuberculosis

Persistent cough greater than a 3-week duration

Been exposed to anyone with tuberculosis

Cough that produces blood

None of the Above

7. Are you taking or have you ever taken Fosamax, Actonel, intravenous bisphosphonates (Aredia or Zometa) medications for bone conditions?

Yes No

If yes, what are the medications or drugs?

And date treatment began?

8. Are you sensitive or allergic to:

Dental Anesthetics (Novocaine),

Penicillin,

Latex,

Bleach,

Codeine,

None of the above

Or any other medications?

Yes No

If yes, what medications or drugs?

9. Have you ever had any history of TMJ (jaw joint) disorders or pain?

Yes No

10. Have you ever had any adverse reactions during prior dental treatment?

Yes No

11. Have you had any surgeries or been hospitalized in the past?

Yes No

If yes, please describe:

Specify any additional conditions you currently or previously had:

For Women Only

12. Are you pregnant?

Yes No

If so, for how many months?

13. Are you nursing?

Yes No

14. Are you taking birth control pills?

Yes No

Signature:

By entering your name below, you certify that all the information provided is accurate and complete to the best of your knowledge and belief:

Signature

Type Your Full Name

Date

Enter Today's Date

DENTAL SERVICES FINANCIAL AGREEMENT

Thank you for choosing Moreno Valley Endodontics. Should you have questions concerning your treatment, treatment sequence, or fees for services, please ask for clarification before treatment is begun.

Our financial policy is as follows:

We accept cash, checks, debit cards, and credit cards.
Payment is due at the time of service.
Payment plans for certain procedures are available through Care Credit with payment options available up to 24 months at fixed rates.
Insurance is a contract between the patient and/or employer and the insurance company. It is not a contract between our office and your insurance company. We will be happy to assist you by filing your insurance claim and answering the details that the insurance company may require. We cannot be responsible for payment by the insurance company. The responsibility for payment belongs to the patient.
We will provide estimated balances between the cost of service and co-payment of your insurance. Predetermination of benefits may be advisable if there is a question concerning coverage.
All remaining balances on your account should be resolved within 10 days of the final insurance payment or financial arrangement.

We reserve the right to accept or deny certain insurance plans at our discretion. If we accept your insurance plan, your copayment is due at the time of service.

I agree to be responsible for all dental charges for dental services and material not paid by my dental plan, unless prohibited by law or the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to your use and disclosure of my protected health information to carry out payment activities in connection with all dental claims.

I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the dentist or dental entity.

Should your insurance plan be denied, full payment is expected at the time of service unless prior arrangements have been made though our office manager.

Please remember that you are responsible for timely payment of your account. "In the event of nonpayment I agree to be responsible for any legal or collection fees. The collection fee is a percentage of the total balance turned over to an outside agency. I agree to be responsible for these fees."

I understand the above policy and agree to the terms herein.

Signature

Type your full name below to acknowledge and accept our Dental Services Financial Agreement as stated above.

Signature

Type Your Full Name

Date

PATIENT HIPAA CONSENT FORM

I understand I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996(HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
Obtaining payment from third party payers (e.g. my insurance company);
The day-to-day healthcare operations of your practice.
Appointment reminder through telephone, text or email.

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions.

However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

Signature

By entering your name below you are acknowledging and accepting this Patient HIPAA Consent Form as stated above.

Signature

Type Your Full Name

Date

СВСТ CONSENT FORM

ACBCT scan, also known as a Cone Beam Computed Tomography, is an x-ray technique that produces 3-D images of your teeth that allows visualization or internal bony structures in cross-section rather than a s overlapping images typically produced ov conventional x-ray exams. CBCT scans are primarily used to visualize bony structures, such as teeth and your jaws, not soft tissue such as your tongue or lips. A dental CBCT will typically capture 3-4 teeth ni a region.

Advantages of a CBCT scan over conventional x-rays: A conventional x-ray of your mouth limits your dentist to a two-dimensional or 2D visualization. Diagnosis and treatment planning can require a more complete understanding of complex three-dimensional or 3D anatomy. Advantages of CBCT scans include:

A) Enhanced patient safety, more predictable outcomes, less discomfort, and faster treatments.

B) Greater chance for diagnosing conditions such as vertical root fractures and endodontic pathology that can be missed on conventional x-rays.

C) Greater chance of providing images and information which may result inthe patient avoiding unnecessary, and sometimes invasive, dental treatment.

Radiation: CBCT scans, like conventional x-rays, expose you to radiation. The amount of radiation you will be exposed to is the the equivalent to what you would receive from several days of normal background environmental radiation. The dose of radiation used is caretully controlled to ensure the smallest possible amount is used that will still give a useful result. However. all radiation is linked with a slightly higher risk of developing cancer (3 in 1,000,000). But the advantages of a CBCT scan outweigh this disadvantage.

Pregnancy: Woman who are pregnant should not undergo a CBCT scan due to the potential danger to fetus. Please tell the dentist if you are pregnant or are planning to become pregnant.

Diagnosis of non-dental conditions: While part of your anatomy beyond your month and jaw may be evident from the scan, your dentist may not be qualified to diagnose conditions that may be present in those areas. If any abnormalities, asymmetries, or common pathologic conditions are noted upon the CBCT scan, ti may become necessary to send the scan to an Oral and Maxillofacial Radiologist for further diagnosis. CBCT scans cannot be relied upon to show soft tissue lesions, unless they have caused changes in the hard tissues (teeth or bone). Also, CBCT images may contain artifacts that can make interpretation difficult. By signing this form, you are acknowledging that your dentist may not be qualified to diagnose al conditions present, and that his/her liability only extends to the limits of the dental purpose of the scan and its interpretation for that purpose.

PLEASE DO NOT SIGN THIS FORM UNLESS YOU HAVE READ IT, UNDERSTAND IT AND AGREE TO ACCEPT THE RISKS AND ADVANTAGES NOTED

Signature

Enter your full name below to acknowledge and accept our CBCT Consent Form as stated above:

Signature

Type Your Full Name

Date

For Office Use Only:

Doctor Signature: x ________________________________________ Date ________ /________ /________

Your information will be encrypted.