Contemporary Family Dentistry

Contemporary Family Dentistry

Seth M. Evetts D.D.S. Sid L. Johnson D.D.S

1117 NW 32nd Street

Newcastle, OK73065

Phone: (405) 387-9300 Fax: (405)387-9398

PATIENT INFORMATION

About You … Contact Information

Spouse Information

Emergency Contact Information

Assignment and Release

Dental History

Reason for today’s visit ______Former Dentist ______

Date of last dental visit ______Date of last dental X-rays ______

Place a mark on “yes” or “no” to indicate if you have had the following.

Bad Breath ___ yes ___ noBleeding gums ___ yes ___ noBlisters on lips or mouth ___ yes ___ no

Dry mouth ___ yes ___ noGrinding Teeth ___ yes ___ noBurning sensation on tongue ___ yes ___ no

Jaw pain ___ yes ___ noSensitive to hot ___ yes ___ noSensitive to cold ___ yes ___ no

Do you smoke or use smokeless tobacco?______How long? ______Have you quit? ______How long ago?______

How often do you brush? ______How often do you floss?______

Health History

Who is your primary care physician?______

Do you drink alcohol? ___ yes ___no How often? ______Has your drinking ever caused you problems? ___ yes ___ no

Have you ever used recreational drugs? ___ yes ___ no Do you currently use drugs? ___ yes ___ no

Have you ever had a serious illness or surgery? ______What and When? ______

Have you ever had a blood transfusion? ______When? ______

Place a mark to indicate if you have had any of the following:

___Anemia___Frequent Headaches___Mitral Valve Prolapse___Stroke

___Angina Pectoris___Glaucoma___Pace Maker___Thyroid Problems

___Arthritis___HIV/AIDS___Psychiatric Problems___Tuberculosis

___Artificial Heart Valve___Heart Attack___Radiation Therapy___Ulcers

___Artificial Joints___Heart Murmur___Rheumatic Fever ___Blood Thinners

___Asthma___Heart Surgery___Seizures

___Cancer - chemo___Hemophilia___Smokeless Tobacco

___Congenital Heart Defect___Hepatitis A___Smoker

___Diabetes___Hepatitis B

___Difficulty Breathing___Hepatitis C

___Emphysema___High Blood PressureWomen: Are you pregnant?______How many weeks?______

___Epilepsy___Kidney ProblemsAre you nursing?______

___Fever Blisters___Liver DiseaseDo you take birth control?______

* Do you take a PREMED before dental appointments? ______

List all Medications you are takingAllergies

______Aspirin___Dental Anesthetics____

______

______Penicillin___Erythromycin___

______

______Codeine___Sulfa___

______

Pharmacy Name______Latex___Other______

______

Pharmacy Phone______

Consent for Treatment

By my signature below, I authorizeDr.Evetts and Johnson to take x-rays, perform dental surgery, administer anesthetic, and provide the dental treatment explained to me in the treatment plan. My signature also verifies my knowledge and understanding of the treatment to be provided. I understand that dentistry, as in all medical treatments, is not an exact science and results of any treatments performed may vary from patient to patient and cannot be guaranteed. I understand that additional surgeries, treatments, or therapies may be required following the initial dental treatment, and I am granting my consent for any and all of these procedures by Dr. Evetts/Johnson, their hygienists, or assistants. Also, by my signature below I hereby certify the correctness and completeness of the medical history information I have provided above. I also understand that I am responsible for payment of all fees and costs resulting from my treatment. I understand that certain procedures may require additional consent.

Patient or Responsible Guardian______Date______

Witness ______

Contemporary Family Dentistry

ACKNOWLEDGEMENT OF RECEIPT OF

NOTICE OF PRIVACY PRACTICES

* You May Refuse to Sign This Acknowledgement *

I, ______have received a copy of this office’s Notice of Privacy Practice.

Please Print Name

Signature

Date

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.

Communications barriers prohibited obtaining the acknowledgement.

An emergency situation prevented us from obtaining acknowledgement.

Other (Please Specify)

© 2002 American Dental Association

All Rights Reserved

Reproduction and use of this form by dentist and their stuff is permitted. Any other use, duplication, or distribution of this form by any other party requires the prior written approval of the American Dental Association.

This form is educational only, does not constitute legal service, and covers only Federal laws, Not State laws (August 14, 2002)

Broken Appointment Policy

Thank you for choosing our office to assist with your dental treatment. In order to give all our patients the best possible care, we request that you review our policy regarding broken appointments.

A broken appointment is defined as: 1) Failure to show up for a previously scheduled appointment or 2) Failure to give 2 FULL BUSINESS days notice to change/ cancel a previously scheduled appointment.

Please remember that we have reserved appointment time specifically for you- we do not double book our patients. Therefore, we request at least 2 FULL BUSINESS days notice to reschedule your reservation. This will enable us to offer your reserved appointment time to another patient.

Any patient that fails to keep their scheduled reservation or fails to give 2 FULL BUSINESS days notice for cancelled/rescheduled appointments will be charged a broken appointment fee of $30.00 for each broken appointment. This charge is not covered by insurance and must be paid prior to rescheduling any future appointments in our office. We also reserve the right to request that any patient who has previously missed a scheduled appointment pre-pay all or part of their anticipated treatment fees prior to scheduling additional appointments in our office.

I have read and understand the policy set forth above:

Print Name

Sign Date