Welcome
We are pleased you have selected us to provide orthodontic care for you and your family
Patient Information
Patient’s Name ______
Address ______
Phone (Home/Work/Cell) ______
SSN# ______Drivers’ License # ______Email Address ______
Birth Date ______Age ______Sex [ ] M [ ] F
Parent/Guardian if patient is a minor ______Relationship to patient ______
If patient is a full-time student, fill in school name ______
School Address ______Phone # ______
Emergency Contact ______Phone # ______
Whom may we thank for referring you to our office? ______
Responsible Party Information
Name ______Relationship to Patient ______
Address ______
Phone (Home/Cell/Fax) ______
SSN # ______Drivers’ License # ______Email Address ______
Birth Date ______Age ______Sex [ ] M [ ] F
Employer ______Occupation ______Work # ______
Insurance Company ______Phone # ______
Insurance Company Address ______Group # ______
Spouses Name ______Relationship to Patient ______
SSN # ______Drivers’ License # ______Email Address ______
Employer ______Occupation ______Work # ______
Insurance Company ______Phone # ______
Insurance Company Address ______Group # ______
Dental Information
What is your main interest in your visit to our office? ______
Are you having pain or discomfort at this time? ____ If yes, please specify ______
Former Dentist ______City ______
Date of last dental visit ______Date of last x-rays ______
Have you had problems with any of the following?
[ ] Bleeding Gums [ ] Periodontal Disease [ ] Sensitivity to Pressure
[ ] Grinding/Clenching Teeth [ ] Sensitivity to Temperature[ ] Sensitivity to Sweets
How do you feel about the appearance of your teeth? ______
Have you ever experienced an adverse reaction during/in conjunction with a dental apt.? ______
Do you have any fear of dental work? ______
Medical History
Name ______Date ______
- Physician’s Name ______Phone # ______
Address ______
- Are you currently under physician’s care? If yes, for what reason ______
- Have you been hospitalized in the last 2 years? If yes, for what reason? ______
- Have you ever taken Fen-Phen/Redux? ______
- Are you sensitive/allergic to dental anesthetic or Latex? If yes, please specify: ______
- Please list your current medications: 7. Please list your drug allergies:
______
______
- Do you have or have ever had any of the following?
High Blood Pressure [ ] Y [ ] NAllergies or Hives [ ] Y [ ] N Hepatitis [ ] Y [ ] N
Angina Pectoris [ ] Y [ ] NSinus Problems [ ] Y [ ] N Venereal Disease [ ] Y [ ] N
Stroke [ ] Y [ ] NAsthma [ ] Y [ ] N A.I.D.S. or H.I.V. Positive [ ] Y [ ] NHeart Disease [ ] Y [ ] N Emphysema [ ] Y [ ] N Blood Transfusion [ ] Y [ ] N
Heart Attack [ ] Y [ ] NTuberculosis [ ] Y [ ] N Hemophilia [ ] Y [ ] N
Heart Surgery [ ] Y [ ] NDiabetes [ ] Y [ ] N Anemia [ ] Y [ ] N
Heart Pacemaker [ ] Y [ ] NThyroid Problems [ ] Y [ ] N Sickle Cell Disease [ ] Y [ ] N
Artificial Heart Valve [ ] Y [ ] NKidney Disease [ ] Y [ ] N Bruise Easily [ ] Y [ ] N
Mitral Valve Prolapse [ ] Y [ ] NUlcers [ ] Y [ ] N Liver Disease [ ] Y [ ] N
Heart Murmur [ ] Y [ ] NCancer or Tumor [ ] Y [ ] N Yellow Jaundice[ ] Y [ ] N
Rheumatic Fever [ ] Y [ ] NRadiation/Chemo [ ] Y [ ] N Cold Sores/Fever Blisters[ ] Y [ ] N
Artificial Joints [ ] Y [ ] NEpilepsy/Seizures [ ] Y [ ] N Cortisone Medication [ ] Y [ ] N
Arthritis/Rheumatism [ ] Y [ ] NFainting/Dizzy Spells [ ] Y [ ] N Drug Addiction [ ] Y [ ] N
Osteoporosis [ ] Y [ ] NNervousness [ ] Y [ ] N Cigarettes[ ] Y [ ] N
- Do you have or have you had any disease, condition or problem not listed? ______[ ] Y [ ] N
If yes, please list: ______
- WOMEN ONLY: Are you pregnant?[ ] Y [ ] NWhat month? ____ Nursing?[ ] Y [ ] N Are you taking birth control?[ ] Y [ ] N
I understand the above information is accurate to the best of my knowledge and is necessary to provide me with dental care in a safe and efficient manner. I will inform the doctor of any change in my medical status.
I authorize the doctor to perform recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated by such treatment.
I authorize my insurance company to pay the dentist all benefits otherwise payable to me for services rendered. I authorize the use of my social security number and my signature on my dental insurance claims.
I understand payment is due in full at time of treatment unless prior arrangements have been approved.
Patient Signature: ______Date ______
Medical History Updates
Date Please note any changes since you last filled out this formPatient Signature Doctor Review
______
______
______
______
SIGNATURE PAGE for: ______Dated: ______
Release of Medical Information
I authorize the release of medical/dental information to my dental office, Gary Ketcherside, to consultants if needed, and to process insurance claims, prescriptions, or to complete any other medical or dental operations as necessary.
Signature: ______Date: _____/_____/______
Financial Policy
Payment is required for all services at the time they are rendered for all applicable co-payments, co-insurance and deductibles. All services performed have separate fees in addition to office visit fee. Patients are responsible to check our participation with their plan as well as their eligibility with their dental plan before their visit. The patient is responsible for any charges not covered by their insurance company. If you must cancel an appointment, please do so at least 24 hours before the scheduled appointment time. A charge of $50 may be applied to patients who miss their appointment or do not notify the office of a cancellation 24 hours in advance. I have read and understand the financial policy statement. I agree to make in-full prompt payment when billed for any and all charges not covered by valid insurance benefits for and in consideration of services rendered. Further I authorize payment directly to Dr. Gary Ketcherside Orthodontics for dental insurance benefits payable to me under the terms of my policy. This authorization is valid until revokes in writing.
The signer must complete their own information here:
Signature: ______Printed Name: ______
Date: ______
Signer’s Address: ______
Signer’s Telephone: ______
Signer’s Date of Birth: ______Signer’s Social Security Number: ______
Privacy Practices (HIPPAA)
Notice of Privacy Practices
- A copy of this notice is available to you. Please ask the reception staff if you would like one. By signing below, I acknowledge that I have offered a copy of our Notice of Privacy Practices.
Contact Information
- By signing below, I authorize Dr. Gary Ketcherside Orthodontics to leave a detailed message in reference to any items that assists the practice in carrying out healthcare operations. If you do not wish to be contacted at a specific location, please indicate below:
Home Phone: Do not contact me hereWork Phone: Do not contact me here
Mobile Phone: Do not contact me hereEmail: Do not contact me here
Please list any persons whom your protected health information can be disclosed (e.g. spouse, parent, etc.)
Name: ______Relationship: ______
Name: ______Relationship: ______
Signature: ______Date: ______/______/______
Dentist-Patient Arbitration Agreement
Article 1: Agreement to Arbitrate: It is understood that any dispute as to malpractice that is as to whether any medical services rendered under arbitration as provided by California law, and not by lawsuit or resort to court process except as California law provides for judicial review of arbitration proceedings. Both parties to this contract, by entering into it are giving up their constitutional rights to have any such dispute decide in a court of law before a jury. And instead are accepting the use of arbitration.
Article 2: All Claims Must Be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or related treatment or service provided by the physician including any spouse or heirs of the patient and any children whether born or unborn at the time of occurrence giving rise to any claim. In the case of any pregnant mother the term “patient” here in shall mean both the mother and the mother’s expected child or children.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician’s partners, associates, association corporation or partnership and the employees, agents and estates of any of them must be arbitrated including without limitation claims for loss of consortium, wrongful death, emotional distress or punitive damages. Filing of any action in any court by the physician to collect fees from the patient shall not waive the right to compel arbitration of any malpractice claim.
Article 3: Procedures and Applicable Law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of a demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitrator, together with the other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees, or other expenses incurred by a party acting in the capacity of arbitrator under this contract. This Immunity shall supplement, not supplant, any other applicable statutory or common law.
Each party shall have the absolute right to arbitrate separately the issues of liability and damages upon written request to the neutral arbitrator.
The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.
The parties agree that provisions of California law applicable to health care providers shall apply to disputes with this arbitration agreement, including, but not limited to Code of Civil Procedures Section 340.5 and 667.6 and Civil Code Sections 3333.1 and 3333.2. any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure section 1283.05, however, depositions may be taken without prior approval of the neutral arbitrator.
Article 4: General Provisions: All claims based on the same incident, transaction or related circumstances shall be arbitrated in once proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedures provisions relating to arbitration.
Article 5: Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered any time for any condition.
Article 6: Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to emergency treatment) patient should initial below.
Effective as of the date of first dental services ______
Patient’s or Patient’s Representative
If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision.
I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.
Notice: by signing this contract you are agreeing to have any issue of dental malpractice decided by neutral arbitration and you are giving up your right to a jury or court trial see Article 1 of this contract.
Patient or Patient/Representative Signature: ______Date: ______
Print Patient/Representative Name: ______Date: ______
Physician’s Authorized Representative Signature: ______Date: ______
Copy available to patient upon request.
Notice of Privacy Practices
This notice describes how your health information may be used and disclosed and how you can access this information. Please read and review all of the following carefully.
At Dr. Gary Ketcherside Orthodontics, we have always kept your health information secure and confidential. Now, a new law requires us to continue in maintaining your privacy, and to provide you with this notice and the following terms under which the law applies.
- We may use or disclose your health information to those involved in your treatment. An example of such would be a review of your file by a specialist who we may involve in your care.
- We may use or disclose your health information for payment services. An example of this would be our sending a report of your progress to your insurance company.
- We may use or disclose your health information for our normal healthcare operations. An example of this would be if one of our staff enters your information into our computer system.
- We may use your medical information with our business associates, such as billing services. We have a written contract with each business associate that requires them to honor and protect your privacy.
- We may use your information to contact you. An example of this would be a confirmation call for an upcoming appointment, a reminder postcard or letter for an overdue appointment, or a message left on an answering machine or with a family member in regards to an appointment.
- We may use or disclose your health information in an emergency, to a family member or another person responsible for your care.
- We may release some, or all, of your healthcare information when required by law.
- If this practice is sold, your information becomes property of the new owner.
We will not use or disclose your health information under any other conditions than the described circumstances above without prior written authorization. If you do not wish your health information to be used or disclosed under the above conditions you may request so in writing, and our office will inform you on whether that request may be fulfilled or not. You have the right to know about any uses or disclosers of your health information under any besides the above uses. As we need to contact you from time to time, we will use whatever address or phone number you prefer. You have the right to transfer copies of your health information to another practice. We will mail the copies for you.
You have a right to see and receive a copy of your health information, with a few exceptions. If you wish to exercise the right to copies of your files, please give my office a written request regarding the specific information you would like to receive. We may charge you a $30.00 duplicating fee for the copies.
You have the right to request an amendment or change to your health information. Please give us a request for any changes in writing. If you would like to include this statement in your file, please request it in writing. We may or may not make the changes you request, but we will be happy to include this statement in your file. If we do agree to amend or change information in your records we will not remove or alter earlier documents, but will add the new information to your preexisting information.
You have the right to receive a copy of this notice. If we change any of the details of this notice, we will inform you of the changes in writing. If you wish to file a complaint, please do so with the Health and Human Services. Complaints maybe addressed to: Health and Human Services
200 Independence Avenue S.W.
Room 509 F
Washington DC 20201
You will not be retaliated against for filing a complaint. However, before filing a complaint please contact at (951)737-3800 for more information or assistance regarding your health information.
This notice is in effect as of April, 14th 2003.
Gary Ketcherside DDS, MS
720 Magnolia Ave. Suite A1
Corona, CA 92879