Alaska Dental Arts North Pole, LLC.
Patient Information
Patient Name: Date:
Last, First MI (Preferred Name)
Birth Date:______Social Security #: ______Gender:______Marital Status: ______
Phone (Home): (Work): Ext: Cell Phone:______
Email:______
Mailing Address:
Street Apartment #
City State Zip Code
Spouse or Responsible Party Information
The following is for: the patient's spouse the person responsible for payment
Name:
Male Female Married Single Child Other
Social Security #: ______Birth Date:
Phone (Home): ______(Work): ______Ext: ______Cell phone::
Address:
Street Apartment #
City State Zip Code
Your Employment Information
The following is for: the patient the person responsible for payment
Employer Name: Occupation:
Address:
Street City, State Zip Code Phone
Insurance Information
Primary
Name of Insured: ______Is insured a patient? Yes No
Last First MI
Insured's Birth Date: ______ID #: ______Group #:
Insured's Address:
Street City State Zip Code
Insured's Employer Name:
Address:
Street City State Zip Code
Patient's relationship to insured: Self Spouse Child Other ______
Insurance Plan Name and Address:
Secondary
Name of Insured: ______Is insured a patient? Yes No
Last First MI
Insured's Birth Date: ______ID #: ______Group #:
Insured's Address:
Street City State Zip Code
Insured's Employer Name:
Address:
Street City State Zip Code
Patient's relationship to insured: Self Spouse Child Other ______
Insurance Plan Name and Address:
Signature of patient, parent or guardian
______Date:
Health Information
· Patient Name: ______Birth Date______
· Physician Name:______
· Are you now under the care of a physician? Yes No
If yes, please explain:
· Have you been admitted to a hospital or needed emergency care during the past two years? Yes No
If yes, please explain:
· Do you have any health problems that need further clarification? Yes No
If yes, please explain:
· Are you taking any medications, over-the-counter or prescribed? Yes No
Name Dosage Frequency
______
______
· Are you taking any vitamins or herbal supplements? Yes No
Name Dosage Frequency
______
______
· Do you use any tobacco products? Yes No
· Do you or have you used recreational or illegal drugs? Yes No
· Are you allergic or had an unusual reaction to any of the following?
Aspirin Penicillin Codeine Local Anesthetic Sulfa Latex Metal Other ______
· Women: Are you: pregnant/trying to get pregnant? nursing? taking oral contraceptives? post-menopausal
Medical History Questionnaire
Date of Last Dental Visit: Reason for this visit:
Have you ever had any of the following? Please check those that apply:
AIDS/HIV positiveAlzheimer’s disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joints
Asthma
Blood Disease
Blood Transfusion
Cancer
Chemotherapy
Cold Sores
Diabetes
Dizziness
Emphysema
Epilepsy
Excessive Bleeding
Fainting
Frequent Cough
Genital Herpes
Gonorrhea
Glaucoma
Hay Fever
Head Injuries
Heart Attack
Heart Disease
Heart Murmur
Heart Pacemaker
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Hemodialysis
Jaundice
Kidney Disease
Leukemia
Liver Disease
Low Blood Pressure
Mental Disorders
Mitral Valve Prolapse
Nervous Disorders
Pain in Jaw Joints
Pregnancy
Due date:______
Radiation Treatment
Respiratory Problems
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sinus Problems
Stomach Problems
Stroke
Syphilis
Thyroid Disorder
Tonsilitis
Tuberculosis
Tumors
Ulcers
Venereal Disease
OTHER:
______
______
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.
______Date:
Signature of patient, parent or guardian
Dental Evaluation
· Have you ever had any complications following dental treatment? Yes No
If yes, please explain:
· Have you been told you have gum disease or periodontal disease? Yes No
· Have you had periodontal surgery? Yes No Dentist Name: ______Date:______
· Are you interested in information about quitting the use of tobacco products? Yes No
· Are you satisfied with your smile? Yes No
Comments: ______
· Are you interested in whitening your teeth? Yes No
Comments: ______
· Have you ever considered cosmetic dentistry? Yes No
Comments: ______
· Have you been diagnosed with TMJ? Yes No
· Do you have frequent pain or muscle tension in your jaw, head or neck? Yes No
· Do you have popping or clicking in your jaw? Yes No
· Are you aware of any clenching or grinding of your teeth? Yes No
· Have you ever worn a bite splint? Yes No
Referral Information
Whom may we thank for referring you to our practice? Another patient, friend Another patient, relative
Dental Office Yellow Pages Newspaper School Work Other
Name of person or office referring you to our practice:
______Date:
Signature of patient, parent or guardian
Financial Policy
IF YOU HAVE DENTAL INSURANCE
As a courtesy to our patients, our office will file claims to the patient’s insurance carrier when all current dental insurance information is provided. Our office recommends that each patient become familiar with their insurance coverage including deductibles, co-pays, and yearly maximums as each insurance company determines their own level of reimbursement. For major services we can submit a pre-estimate, when requested.
Please remember, payment for professional services is the responsibility of the patient. Services are provided without the assumption they will be paid for by an insurance company. Any balance after payment by insurance is due in 30 days. Major services require 50% patient payment at the time of service. We require advance payment for all initial visits and emergency patients with or without insurance coverage. Interest will be charged on all accounts at the rate of 1.5% ($1.00 minimum).
Cancellation Policy
There will be a $50.00 cancellation fee if the appointment is cancelled with less than 24 hours notice.
I hereby authorize Alaska Dental Arts North Pole LLC. P.C. to furnish the insured’s insurance carrier(s) information that said insurance carrier may request concerning claims. I hereby assign to Alaska Dental Arts North Pole, LLC. P.C. all money to which I am entitled for expenses related to the services performed from time to time, but not to exceed my indebtedness to, Alaska Dental Arts North Pole, LLC. It is understood that any money received from my insurance company over and above my indebtedness will be refunded to be when my bill is paid in full. I understand that I am financially responsible to Alaska Dental Arts LLC for charges not covered by this agreement.
______Date: ______Relationship to Patient:
Signature of patient, parent or guardian
IF YOU DO NOT HAVE DENTAL INSURANCE
Payment in full is due at the time of service. We require advance payment for all initial visits and emergency patients. This office does not extend personal lines of credit. Interest will be charged on all accounts at the rate of 1.5% ($1.00 minimum).
Please indicate your preferred method of payment.
Cash or Money order
Visa / MasterCard / Discover / Debit Card
Care Credit (no interest/short term and low interest/extended term plans available)
Cancellation Policy
There will be a $50.00 cancellation fee if the appointment is cancelled with less than 24 hours notice.
I understand that I am personally responsible for all charges incurred at the office of Alaska Dental Arts
______Date: ______Relationship to Patient:______
Signature of patient, parent or guardian
Patient Consent Form
I understand that 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:
Ø Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
Ø Obtaining payment from third party payers (e.g. my insurance company);
Ø The day-to-day healthcare operations of your practice
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 I 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.
Signed this ______day of ______, 20___.
Print Patient Name:______
Relationship To Patient:______
Signature:______
Alaska Dental Arts North Pole, LLC
203 S. Santa Claus Lane
North Pole, Alaska
99705
(907) 490-4650