TIME 9:06AM McKaskle Family Dentistry DATE 2/20/2013 MEDICAL HISTORY PATIENT NAME ________________________________________ Birth Date ___________________________________________ Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under a physician's care now? __ Yes __ No If yes, please explain: ______________________________ Have you ever been hospitalized or had a major operation? __ Yes __ No If yes, please explain: ______________________________ Have you ever had a serious head or neck injury? __ Yes __ No If yes, please explain: ______________________________ Are you taking any medications, pills, or drugs? __ Yes __ No If yes, please explain: ______________________________ Do you take, or have you taken, Phen-Fen or Redux? __ Yes __ No Have you ever taken Fosamax, Boniva, Actonel or any __ Yes __ No other medications containing bisphosphonates? Are you on a special diet? __ Yes __ No Do you use tobacco? __ Yes __ No Do you use controlled substances? __ Yes __ No Women: Are you Pregnant/Trying to get pregnant? __ Yes __ No Taking oral contraceptives? __ Yes __ No Nursing? __ Yes __ No Are you allergic to any of the following? __ Aspirin __ Penicillin __ Codeine __ Local Anesthetics __ Acrylic __ Metal __ Latex __ Sulfa drugs __ Other If yes, please explain: ______________________________ Do you have, or have you had, any of the following? AIDS/HIV Positive __ Yes __ No Alzheimer's Disease __ Yes __ No Anaphylaxis __ Yes __ No Anemia __ Yes __ No Angina __ Yes __ No Arthritis/Gout __ Yes __ No Artificial Heart Valve __ Yes __ No Artificial Joint __ Yes __ No Asthma __ Yes __ No Blood Disease __ Yes __ No Blood Transfusion __ Yes __ No Breathing Problem __ Yes __ No Bruise Easily __ Yes __ No Cancer __ Yes __ No Chemotherapy __ Yes __ No Chest Pains __ Yes __ No Cold Sores/Fever Blisters __ Yes __ No Congenital Heart Disorder __ Yes __ No Convulsions Cortisone Medicine __ Yes __ No Diabetes __ Yes __ No Drug Addiction __ Yes __ No Easily Winded __ Yes __ No Emphysema __ Yes __ No Epilepsy or Seizures __ Yes __ No Excessive Bleeding __ Yes __ No Excessive Thirst __ Yes __ No Fainting Spells/Dizziness __ Yes __ No Frequent Cough __ Yes __ No Frequent Diarrhea __ Yes __ No Frequent Headaches __ Yes __ No Genital Herpes __ Yes __ No Glaucoma __ Yes __ No Hay Fever __ Yes __ No Heart Attack/Failure __ Yes __ No Heart Murmur __ Yes __ No Heart Pacemaker __ Yes __ No Heart Trouble/Disease __ Yes __ No Hemophilia __ Yes __ No Hepatitis A __ Yes __ No Hepatitis B or C __ Yes __ No Herpes __ Yes __ No High Blood Pressure __ Yes __ No High Cholesterol __ Yes __ No Hives or Rash __ Yes __ No Hypoglycemia __ Yes __ No Irregular Heartbeat __ Yes __ No Kidney Problems __ Yes __ No Leukemia __ Yes __ No Liver Disease __ Yes __ No Low Blood Pressure __ Yes __ No Lung Disease __ Yes __ No Mitral Valve Prolapse __ Yes __ No Osteoporosis __ Yes __ No Pain in Jaw Joints __ Yes __ No Parathyroid Disease __ Yes __ No Psychiatric Care __ Yes __ No Radiation Treatments __ Yes __ No Recent Weight Loss __ Yes __ No Renal Dialysis __ Yes __ No Rheumatic Fever __ Yes __ No Rheumatism __ Yes __ No Scarlet Fever __ Yes __ No Shingles __ Yes __ No Sickle Cell Disease __ Yes __ No Sinus Trouble __ Yes __ No Spina Bifida __ Yes __ No Stomach/Intestinal Disease __ Yes __ No Stroke __ Yes __ No Swelling of Limbs __ Yes __ No Thyroid Disease __ Yes __ No Tonsilitis __ Yes __ No Tuberculosis __ Yes __ No Tumors or Growths __ Yes __ No Ulcers __ Yes __ No Venereal Jaundice __ Yes __ No Yellow Jaundice __ Yes __ No Have you ever had any serious illness not listed above? __ Yes __ No Comments: ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ ________________________________________________________________________ To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status. __________________________________________________________________________________ SIGNATURE OF PATIENT, PARENT, or GUARDIAN __________________________________ DATE ______________________________ FINANCIAL POLICY We value you as a patient and are committed to providing you with the best possible dental care. We want you to have a complete understanding of your financial responsibilities for the services to be provided. To assist us in achieving these goals, we ask that you review our financial policy. Unless payment arrangements have been approved in advance by our authorized staff, payment in full will be due at the time services are rendered. We will be happy to help process your claim for reimbursement or you may assign your primary insurance benefits to the doctor as partial payment toward the services rendered. This can be done after we have had the opportunity to verify your primary insurance benefits. If you have secondary insurance benefits, we will process your claim for reimbursement directly to you. At the time of your appointment, you will be expected to pay your deductible as well as any portion of the treatment fees that we estimate will not be covered by your insurance policy. Because of insurance policy changes and/or necessary changes in treatment plans, your dental coverage may vary from this estimated treatment calculation or your carrier’s pre-estimate. If your insurance company has not paid the full balance of the claim within 60 days from treatment date, you will be responsible for paying the balance. Please remember that your insurance is a contract between you and your insurance company and/or employer. Our dental practice is not a party to the contract. It is your responsibility to verify coverage and charges with the insurance company, as well as to verify that this office has the correct insurance information, including plan information. A finance charge of 1.5% per month may be assessed to accounts with balances outstanding for 60 days from treatment date. This FINANCE CHARGE represents an ANNUAL PERCENTAGE RATE of 18%. If your check is dishonored or returned for any reason you expressly authorize our office to electronically debit your bank account for the amount of the check, plus a $25.00 processing fee. Your use of a check for payment is your acceptance of this agreement and its terms. All treatment charges are the responsibility of the patient or responsible party regardless of insurance coverage. In the event of non-payment, the patient or responsible party agrees to pay all the costs of collection including but not limited to attorney fees, court costs, collection agency fees, etc. No charge will be made for rescheduling an appointment provided 24 hours notice is given. Otherwise, a minimum charge of $25.00 will be charged. Once an appointment has been made, please remember this time has been specifically reserved for you. The missed appointment fee is not a covered expense of your insurance company. I have read and understand the financial policy of this practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time to time by the practice. Signature of Patient/Parent, or Guardian __________________________________ Date ______________________________ McKaskle Family Dentistry Your Privacy Is Important to Us Acknowledgement of Receipt of Notice of Privacy Policies I have received a copy of the Notice of Privacy Practices of McKaskle Family Dentistry. I hereby authorize, as indicated by my signature below,McKaskle Family Dentistry to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose, as authorized in the Patient Consent form. Print Name __________________________________ Address __________________________________ Signature __________________________________ Date __________________________________ Please provide your contact information: Home telephone number: __________________________________ Mobile telephone number: __________________________________ Work telephone number: __________________________________ Email: __________________________________ Other __________________________________ *Please do not provide any contact information that you would not like for us to use in reaching you* * * * For Office Use Only: We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: __ Individual refused to sign __ Communication barriers prohibited obtaining the acknowledgement __ An emergency situation prevented us from obtaining the acknowledgement __ Other (Please Specify) __________________________________ Staff Person Initials __________________________________