LAKE RIDGE DENTAL CLINIC
PATIENT INFORMATION FORM
Date______
Name/MI/First______
Date of Birth______Sex______Single____ Married_____
Address______
City______State______Zip______
Home phone ______Work Phone______Cell #______
Social Security #______
Patient’s Employer______
Business Address______City______State_____ Zip______
Name of dental insurance / if any ______
Subscriber’s name, DOB & SSN ______
Subscriber’s employer & address ______
Name of additional insurance / if any______
Subscriber’s name, DOB & SSN ______
Party responsible for this account ______
Address______City______State ______Zip______
Social Security # ______
Emergency contact name and phone # ______
Relationship to patient ______
***MEDICAL HISTORY***
We are concerned about your total health in order to provide safe and comprehensive dental care.
We therefore ask that you provide us with the following information:
Physician ______Office phone# ______date of last exam ______
Please indicate which of the following applies to you. Check only if answer is YES.
Are you under medical treatment? Are you taking any medication including
Have you ever been hospitalized for non-prescription medicine? If yes, what
any surgical or serious illness? medication(s)?______
Do you use tobacco? Are you allergic to or have you had any
Do you use alcohol, cocaine or other drugs? reactions to any drugs? If yes, please specify
Are you wearing contact lenses? ______
Heart disease/ Heart attack Chest pain Cardiac pacemaker
High blood pressure Heart murmur Stroke
Low blood pressure Angina Allergies
Rheumatic fever Asthma Tuberculosis
Emphysema Cancer Radiation therapy
Fainting/Seizures Epilepsy Glaucoma
Leukemia Arthritis Frequently tired
Diabetes Joint replacement or implants
Stomach trouble/Ulcer AIDS or HIV infection
Thyroid problems Hepatitis/Jaundice
Other------
Women Only:
Are you pregnant or think Are you nursing? Are you taking birth control pills?
you may be pregnant?
***DENTAL HISTORY***
Last dental visit ______Last dental exam and cleaning ______
Last time you had a full set of dental x-rays taken ______
If last dental visit was with a dentist other than Dr. Mina Mostofi, please provide us with the following information: Dentist ______Office phone number ______
Please indicate which of the following applies to you. Check only if the answer is YES.
Do your gums bleed while brushing or flossing? Do you clench or grind
Are your teeth sensitive to hot or cold liquids/foods? your teeth?
Are your teeth sensitive to sweet or sour liquids/foods? Have you ever had any
Do you feel pain to any of your teeth? difficult Extractions?
Do you have any sores or lumps in or near your mouth? Have you ever had prolonged
Have you ever experienced any of the following bleeding after extractions?
Problems in your mouth? Have you had any orthodontic
Clicking treatment?
Difficulty in opening or closingHave you ever had instruction on
Difficulty in chewing? the correct method of brushing your teeth?
Would you like to change the appearance of your smile?
Would you like to know more about tooth whitening system?
Would you like to know more about cosmetic dentistry?
I certify that I have read and understand the patient information form and the information I provide is accurate and complete to the best of my knowledge. I understand the information I have provided is to be used only for the purpose of my treatment by my dentist, billing purposes related to such treatment, and for the processing of my insurance claim related to such treatment. I will not hold my dentist or members of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
Patient’s signature (if minor, parent or Guardian’s name and signature) ______
We expect our patients to abide by the following office policies:
(A minor’s, parent or guardian should sign, and print the minor’s name.)
CONSENT TO DENTAL TREATMENT:
I authorize Lake Ridge Dental Clinic to perform any dental services that it deems reasonably necessary in my dental treatment. I have been given no guarantees or assurances of any kind by anyone as to the results that may be obtained. I understand that unforeseen conditions or circumstances may arise during the course of any procedure or treatment. I authorize the performance of all procedures and treatment that the dentist believes necessary or advisable as a result of these unforeseen events. I consentto the administration of local anesthetic that the dentist deems necessary and understand that there are risks involved with the administration of anesthesia.
______
SignatureDate
ASSIGNMENT AND RELEASE:
I authorize the release of all medical, dental, and/or surgicalinformationnecessary to process my insurance claims.I hereby authorize payment of dental benefits to Lake Ridge Dental Clinic for all dental, and/or surgical treatments performed by them and covered by my insurance.
______
SignatureDate
FINANCIAL AGREEMENT:
Lake Ridge Dental Clinic will aid you in filing your insurance claims. If you have multiple insurance services we will file your claim, however the co-payment will be calculated based on your Primary Carrier. You will be reimbursed if you overpaid for our services after all claims have been paid. Remember that the co-payment (portion that is not covered by your insurance) and yearly deductible is due at the time of treatment. Please be advised that your insurance policy is a contract between you and your insurance company and we are not a party to that contract. It is your responsibility to make sure that you are covered at the time of service. If for any reason your insurance company does not cover a procedure or denies your total charges, it is ultimately your full responsibility to pay for the services as soon as possible. If your insurance company has not made payments within 60 days of billing, the balance will become your responsibility. If your insurance policy is an HMO or a reduced cost plan, you are responsible for the entire treatment cost as described by your insurance policy at the time of service. If for any reason your account is referred to any collection service, you will be responsible for both your balance with Lake Ridge Dental Clinic and all related charges attributable to the collection service.
We are required by law to keep original x-rays on file. Copies of full mouth x-rays or panoramic x-rays are $50 each, single x-rays $7.00 each.
______
SignatureDate
BROKEN APPOINTMENT:
You must notify us at least 24 hours in advance if you are unable to keep your appointment.
We have set aside this time for you and if you do not inform us in advance, a broken appointment charge of $30.00 per half hour appointment time will be applied to your account.
______
SignatureDate
Notice of deemed consent for
HIV – HBV – AND – HCV
As a health care provider, we are required by 32.1-45 of the Cod of Virginia (1950) as amended, to give you the following notice.
1)If one of your health care professionals or their workers or employees should be directly exposed to your blood or bodily fluids in a manner that would ordinarily lead to the transmission of diseases, the law requires that your blood be tested for infection with the human immune deficiency virus (“HIV” or the “AIDS” virus) and for the presence of the Hepatitis B and Hepatitis C viruses. A physician or other health care provider will notify you, the patient, and the person to whose blood/bodily fluids you were exposed of the result of such test and provide counseling if necessary.
2)If you should be directly exposed to blood or body fluids of one of our health care professionals, workers or employees in a way that may transmit disease, that person’s blood will be tested for infection with human immune deficiency virus “HIV”, the “AIDS” virus and for the presence of Hepatitis B and Hepatitis C virus. A physician or other health care provider will tell you and that person the results of the test and provide counseling if necessary.
I have read and understand the deemed consent notice and hereby authorize Dental Family Practice to render care to me and / or my dependent.
This consent remains in effect as long as I receive care at Dental Family Practice or until
I withdraw it in writing.
______
Signature of Patient, Parent/Legal Guardian Date
Or person acting in Loco Parentis
______
Print Patient NameRelationship to patient
(If not patient’s signature)