PATIENT INFORMATION ____ _ CONFIDENTIAL Name_____________________________________ Birthdate___________________ Soc. Sec. #_________________________ Address___________________________________ City_______________________ State______ Zip__________________
Sex (M/F)______ Marital Status____________ Home #______________________ Cell #___________________________
Employer_________________________________ Address_______________________________________________________ Work #______________________ Length of Employment_______________ Position Title_________________________ Do you prefer to receive calls at: ____Home ____Work ____Either Person to contact in case of an emergency:_____________________________ Phone #________________ How did you find out about our Office:________________________________________________________ SPOUSE OR PARENT/GUARDIAN INFORMATION______________________________________________
Name_____________________________________ Birthdate__________________ Relationship to Patient_______________ Address___________________________________ City_______________________ State______ Zip__________________
Sex (M/F)______ Marital Status____________ Home #______________________ Cell #___________________________
Employer_________________________________ Address_______________________________________________________ Work #______________________ Length of Employment_______________ Soc. Sec #_________________________ RESPONSIBLE PARTY_______________________________________________________________________
Name_____________________________________ Birthdate__________________ Relationship to Patient_______________ Address___________________________________ City_______________________ State______ Zip__________________
Sex (M/F)______ Marital Status____________ Home #______________________ Cell #___________________________
Employer_________________________________ Address_______________________________________________________ Work #______________________ Length of Employment_______________ Position Title_________________________ Is this person currently a patient at our office? _____Yes _____No Soc. Sec. #___________________________
Name of Primary Insured___________________________ Birthdate____________ Relationship to Patient_______________ Home #______________________ Cell #_____________________ Employer_____________________________________ Dental Ins. Co. Name___________________________ Phone #_________________ Subs. /Emp. ID #__________________ Dental Ins. Co. Address___________________________ City_________________ State________ Zip______________ Name of Secondary Insured________________________ Birthdate_____________ Relationship to Patient_______________ Home #_______________________ Cell#_________________________ Employer___________________________________ Dental Ins. Co. Name____________________________ Phone#___________________ Suds./Emp. ID#___________________ Dental Ins. Co. Address__________________________ City____________________ State_________ Zip________________ Please read each of the following policies completely before placing your initials on the corresponding line. By placing your initials on the line you are agreeing that you have fully read and understand our office policies. AUTHORIZATION, RELEASE, and AGREEMENT TO PAY FOR SERVICES RENDERED_______ I authorize Dr. Volz to release any information including the diagnosis and the records of any treatment of examination rendered to me during the period of such Dental care to third party payors and/or other health practitioners. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or on behalf of my dependents. ___________ PAYMENT METHODS and FINANCE CHARGE_____________________________________________
There are two forms of payment that are accepted; those being personal check or cash. My portion of payment is expected at the time of the service. Also if I do not pay the entire account balance within 30 days of the monthly billing date, a finance charge of 2% per month or a minimum of $2.00 per month will be placed on my account. I realize that failure to keep this account current may result in you being unable to provide additional dental services except for dental emergencies or where there is prepayment for additional services. In the case of default on payment of this account, I agree to pay collection costs and reasonable attorney fees incurred in attempting to collect on this amount or any future outstanding account balances. ___________ CANCELLATIONS WITHOUT 24HR NOTICE OR FAILURE TO APPEAR_____________________
Canceling appointments without 24hr notice or failure to appear for a dental appointment will be handled in the following way: FIRST OCCURENCE: a verbal warning is given to patient or responsible party SECOND OCCURENCE: a $30.00 fee is charged to your account and must be paid before any further appointments are made THIRD OCCURENCE: you must prepay for any scheduled treatment; however if that appointment is cancelled without 24hr notice or failure to appear occurs, then the prepayment is forfeited __________ (INITIALS) INFORMED CONSENT___________________________________________________________________
I give this practice permission to disclose or use my protected health information to carry out my treatment(s), payment activities and health care operations. ___________ ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES________________ (You May Refuse to Initial This Acknowledgement) I, _____________________________, have received a copy of this office’s Notice of Privacy Practices. ___________
(INITIALS) IF SIGNING FOR A MINOR Print Name of Minor___________________________________ Parent/Guardian of Minor Initials___________
I understand that by signing this form, that I have been informed of this Office’s policies. Patient or Parent/Guardian’s Signature:___________________________________ Date:__________________ PATIENT MEDICAL AND DENTAL HISTORY__________________________________CONFIDENTAL Physician Name____________________________________ Phone #___________________ Date of Last Exam________________
Please Circle Y for Yes or N for No 1. Are you under going medical treatment now 4. List any medications including non-prescription medications Y N __________________________________________________________ __________________________________________________________ 2. Have you ever been hospitalized for a _________________________________________________________ _ major operation or serious illness Y N 5. Please circle any of the following that you may be allergic to or may have/had a reaction to Local Anesthetics Penicillin Antibiotics Barbiturates 3. Do you use or have you ever used any form of Osteoporosis preventing drugs Sulfa Drugs Aspirin Iodine such as: Fosamax, Boniva, Actonel, Skelid, Didronel, Zometa, and/or Aredia Please list Others__________________________________________ Y N _________________________________________________________ WOMEN ONLY: 1. Are you pregnant or think you may be pregnant Y N 2. Are you nursing Y N 3. Are you taking birth control pills/patch/shot/other Y N Do you have or have you had any of the following? If yes, please mark with an X
_____Heart Attack/Problems _Joint Replacement/Implant Respiratory Problems _____Emphysema/COPD _ __Fainting/Seizures/Epilepsy _____Tuberculosis _____Stomach Ulcers _____Hepatitis/Jaundice _____Heart Murmur AIDS/HIV+/STD _____Nervous/Mental Problems _____Seasonal Allergies _____Cancer _____High/Low Blood Pressure _____Rheumatic Fever Cold Sores _____Diabetes _____Excessive Bleeding _____Radiation Therapy _____Stroke How long since your last dental visit?____________ How often did you visit a dentist before then?____________
Did you have x-rays? Y N How often do you brush your teeth___________ How often do you floss__________
Do you use alcohol and/or tobacco? Y N Do you use any other drug? Y N
Do you have any of the following habits: ____thumb/finger sucking Chewing on ____Cheek ____Tongue ____Lips ____Pencils/Pens ____Fingernails
Please mark an X by any of the following statements that may apply to you _____Do your gums bleed while brushing or flossing _____Do you want to avoid dentures _____Do you feel pain in your mouth or teeth _____Have you had pain in or around your ears _____Have you had complications with extractions _____Do you clench or grind your teeth _____Are your teeth sensitive to heat/cold/sweets/sour things _____Does food wedge between your teeth _____Do you have sores/lumps in or near your mouth _____Do you experience popping, clicking, or snapping when chewing _____Do you have or ever had braces If so, when_____________ _____Have you ever had gum treatment or surgery If so, when______________ _____Have you had any head, neck, or jaw injuries If so, when______________ I certify that to the best of my knowledge the foregoing questions have been completely and accurately answered. I also understand that providing incorrect information can be dangerous to my health.
Martes, 6 de junio 2006 B.O.C. y L. - N.º 108 El cómputo del plazo para la interposición de ambos recursos se inicia-Examinadas las solicitudes presentadas, a propuesta de la Comisiónrá a partir del día siguiente a la notificación personal a los interesados, y ende Selección constituida a tal efecto conforme establece la base séptimarelación con los demás que pudieran tener ta
GOLD COAST PLASTIC SURGERY, LLC SURGERY MEDICATIONS Aspirin, aspirin-related products, ALL herbal products and Vitamin E must not be taken during the two weeks prior to and after surgery because they increase bleeding. For this reason, it is very important that contents of any “over the counter preparations” are checked carefully prior to their use. Many headache preparat