Kajlua.Dental Arts 970 N. Kalaheo Avenue, Suite A305 Ka*lua, HI 96734 tel: 808.254.5454 fax: 808.,254.,5427 www,,Ka*lluaDentalArts.com Thank you for selecting our dental team! The information you provide in these forms i *s kept confidential and will help us provide the best dental care we know how. We are here to assist you in any way possible. Please voice any questions or concerns to our t We want you to fully understand your dental health and help assist you make the best choices possible for you. Today's Date: Patient Information Patient name (First/Last) Preferred Name: Gender: LIMale LIFemale Family Status: USingle LIMarried LJChl'Id Date of Birth: Phone #'s (Home) (Work) Ext: Email: Where do you prefer to receive calls? How would you prefer to be contacted: Home Address: Street Mailing Address (if different) (Cell #) Best time to call: Home Work LJ Cell Phone call Email Apartment I Unit # City State Zip Street City State Zip Occupation: Employer: Spouse's Information: Name: Phone#. * * Military Family Members: Estimated PCS date (Month & Year you may leave Hawaii): In case of an emergency, who should we contact? Relationship: Emergency contact phone numbers: Who may we thank for referring you to our practice? Dental Insurance Information #11rimaKI Dental Insurance: Ins. C Group #: Name of the Insured employee /Policy holder: Is insured a patient? UY UN Policy holder's Birth Date: Social Security Number or Subscriber ID#1 Patient's relationship to insured I employee: Self Spouse Child Other #2 Secondary Dental Insurance: Ins. Company: Group #: Name of the Insured employee /Policy holder: Is insured a patient? UY UN Insured's Birth Date: Social Security Number or Subscriber ID#. Patient's relationship to insured I employee: Self Spouse Chl*ld Other
Transcript
Kajlua.Dental Arts 970 N. Kalaheo Avenue, Suite A305 Ka*lua, HI 96734 tel: 808.254.5454 fax: 808.,254.,5427 www,,Ka*lluaDentalArts.com
Thank you for selecting our dental team! The information you provide in these forms i*s kept confidential and will help us provide the best dental care we know how.
We are here to assist you in any way possible. Please voice any questions or concerns to our t We want you to fully understand your dental health
and help assist you make the best choices possible for you.
Today's Date: Patient Information
Patient name (First/Last)
Preferred Name:
Gender: LIMale LIFemale Family Status: USingle LIMarried LJChl'Id
Date of Birth:
Phone #'s (Home)
(Work)
Ext:
Email:
Where do you prefer to receive calls?
How would you prefer to be contacted:
Home Address: Street
Mailing Address (if different)
(Cell #)
Best time to call:
Home
Work LJ Cell
Phone call Email
Apartment I Unit #
City
State
Zip
Street
City
State
Zip
Occupation:
Employer:
Spouse's Information: Name:
Phone#.
* * Military Family Members: Estimated PCS date (Month & Year you may leave Hawaii):
In case of an emergency, who should we contact?
Relationship:
Emergency contact phone numbers:
Who may we thank for referring you to our practice?
Dental Insurance Information
#11rimaKI Dental Insurance: Ins. C
Group #:
Name of the Insured employee /Policy holder: Is insured a patient? UY UN
Policy holder's Birth Date: Social Security Number or Subscriber ID#1
Patient's relationship to insured I employee: Self Spouse
Child Other
#2 Secondary Dental Insurance: Ins. Company: Group #:
Name of the Insured employee /Policy holder: Is insured a patient? UY UN
Insured's Birth Date:
Social Security Number or Subscriber ID#.
Patient's relationship to insured I employee:
Self Spouse
Chl*ld Other
Kail,aa Dental Arts 970 N. Kalaheo Avenue, Suite A305 Ka*llua,Hl 96734
Our office is not like most other dental offices. This may be the most important dental visit you will ever have. place a high emphasis on helping you determine your present and future dental needs. Please check what best
0 expresses how you feel about the following questions:
We
. Are you having any areas of concern?
. Has fear ever been an issue for you in a dental office?
. What caused you to leave your last dental office?
. Has time ever been a factor in getting your dental work done?
. Has the cost of dental treatment been a concern for you?
. What can we do to help you with this?
Is there any addl'tional informati on you would like us to know?
Health Information
We understand that you are here for us to help you care for your teeth and gums. Medications you are taking and health problems you may have could make a difference in how we treat your dental problems. Thank you for your assistance.
MEDICATION LIST: Date Medication Name Purpose Dosage__
Physician Name Phone Number
Do you see a Specialist? (For example: Cardiologist, Orthopedist, Internist,, etc)
Medical Specialist Name Phone Number
Are you currently under the care of a physician? Ll Yes No If Yes,, for what.?
When did you last visit your physician?
You consider your health to be: Excellent Good
Fair
Poor
Have you been admitted to a hospital, had surgery or needed emergency care during the past two years'.? L3Yes LJNo
If yes, please explain:
Circle ves (111 or t-o answer the following:
Are you allergic to any of the following? T/W Aspirin Tlx Erythromycin
* Health Fact: Gum disease and dental infections may increase the risk of stroke and coronary heart disease. Bleeding
TIN Excessive bleeding Tlgv Blood Transfusion Tlx Take blood thinning medication cy/gr Hepatitis A B Tlx Jaundice 'Y/ft( Anemia
Diabetes TIN Type 1 Diabetes Tlx Type 2 Diabetes cylx Diet (Special/Restricted)
* 0 Health Fact: Medical studies have shown a link between diabetes and periodontal (gum) disease. It is important to your health that they both are under control. The warning signs of diabetes are frequent trips to the bathroomth*1rsty all the time, and always feeling hungry. Breathing Lunias
T19V Sinus problems cylx Asthma Tlgv Snoring *Ask your spouse!*
Y/W Seasonal Allergies Y/w Emphysema Tlgv Hard to breathe through nose '11W Tuberculosis Tlx Bronchitis Tlx Wake up tired
Cancer 'Y/sir Radiation Therapy Tlx Chemotherapy Cancer Type:
Immune-Svstem T/N Lupus T/Y Organ Transplant T19v HIV I AIDS
Nerves/muscles/B ones T19V Head Injury Tlx Arthritis Tlx Thyroid Condition T/N Vertigo Tlx Back problems Tlx Epilepsy
T/Y Tinnitus (ringing in ears) 'Y/r Scoliosis TIX U Migraines Headaches (Y/g%( Bell's Palsy Tly Ear Congestion Tlx Paresthesia of fingertips (tingling) T19Y Trigeminal Neuralgia Tlx Osteoporosis
T/N Artificial Joints: Placed When? joint?
General Ouesti*ons Tlx Do you use tobacco? Type: Ci*garettes Ci*gar Tlx Have you been told you have Acid Reflux? Tlx Do you use Cortisone Medication? Reason: Tlx Do you get Cold Sores/Fever Blisters? How often?
Chew How much?
Do you have any other health problems you feel we need to know about?
Women Only:
7/N Are you pregnant? If yes: What is Baby's Due Date? 7/N Are you breastfeeding? (y/gr Are you taking birth control pills? Tlx Are you on hormone therapy?
I understand taking antibiotics may render oral contraceptive ineffective. Initials
Health Fact: Periodontal (gum) infections can increase the risk of low birth weights in newborns
Date
Dental Information
Reason for today's visit:
Name of Previous Dentist: Phone #:
Date of last dental visit:
When was your last dental cleaning?
Last x-rays?.
7/.N Have you ever had a seri*ous/difficult problem associated with any previous dental treatment? If yes, what:
(Y/gs[ Are any of your teeth sensitive? If yes, to what: OCold ❑Heat ElChewing LII Other y/gr Have you been advised to take antibiotics routinely prior to dental treatment? Y/N Reason
(Y/w Do you brush your teeth daily? How many times? Do you floss? How often? Do your gums bleed? Have you ever had gum treatment? Have you had braces /orthodontic treatment? Do you have any loose teeth?
(Y/gs[ Do you know or ever been told you grind your teeth? (Y/.N Do you experience jaw joint: cll*c n 9 popping locki'sng T1x Do you have difficulty: ❑swallowing ❑chewing? Y/w Do you have frequent: headaches neck or back pain?
jaw/ uscle fatigue?
r/g%[ I gag easily T15%r Would you like whiter teeth? T Y Have you whitened your teeth before? Which system?
I understand that the information that I have given is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my personal information and/or my medical status including changes in my medications.
Patient Signature
Date
if patient is minor = Print Name of Parent or Guardian
Signature
Relation to Patient
Kailua Den,wAzYs
* Theignformation in this document is important, please read and initial the foiowinx.
Consent for Services Initial I authorize the dentist and/or staff to take x-rays, models, photographs, and other diagnostic aids
deemed appropriate by the dentist to make a thorough diagnosis and upon such diagnosis, I authorize the recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper Care.
Initial I understand that the photographs, slides, and/or x-rays may be used for educational purposes in lectures, demonstrations, advertising (including website publication), and professional publications (dental magazines and journals). I further understand that 1*f the photographs, slides., and/or x-rays are used in any publication or as a part of a demonstration, my name or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these photographs.
Appointment Guidelines Initial
A portion of the fee for services will be collected at the time treatment is scheduled. The amount paid will be applied towards your patient portion for services provided. If you need to change your appointment, kindly give at least a 48 hours notice. If an appointment is cancelled without a 48 hour notice, the reservation fee will be forfeited and an additional $50 would be required to make a new appointment.
Initial
Failure to show for an appointment without any notice may result in dismissal from the practice for yourself and immediate family.
Dental Insurance Insurance coverage i*s a contract between you, your employer, and your insurance company. As we are not representatives of your insurance company, any insurance e stl*mates discussed are estimates only and are not a guarantee of payment. This office will help prepare your insurance forms or assist in making collections from insurance companies and will credit any such collections to your a
Initial I agree to inform the office if there are ever any changes to my insurance coverage. Initial I understand that all dental services furnished by this office are charged directly to me and that I
am personally responsible for payment of all dental services. I also understand I am responsible for paying all charges not covered by my insurance company, including all fees above what the insurance calls "usual and customary".
Insurance Assignment: I hereby authorize payment of any insurance benefits otherwise payable to me, directly one of the following: Kailua Dental Arts, Marcus Hannah, DDS, and Lisa Sonntag, DDS.
Signature: Financial Policies
Initial
I understand that checks that are returned unpai*d are subject to a $25.00 fee. Ini"ti"al In consideration for the professional services rendered to me by Kailua Dental Arts staff, I agree
to pay the reasonable value of said services to the practice at the time said services are rendered, or within five (5) days of billing if credit shall be extended. I further agree that the reasonable value of said services shall be as billed unless objected to, by me, in writing, within the time for payment thereof. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees 1*f suit were instituted hereunder.
Initial Hawaii charges a 4.712% tax for medical and dental services. By law, we are required to collect this for the state.
I have read and understand the above conditions and agree to their content.
Printed Name of patient(s): Date:
Signature of Patient (if patient is a minor, the parent, or guardian) Relationship to patient
Signature of guarantor of payment I party accepting financial responsibility for account Relationship to, patient
Acknowledgement of Receipt of Notice of Privacy Practices
have reviewed a copy of this dental office's Notice of Privacy Practices. (printed name of patient)
Please Print Patient Name(s):
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:
Ei Individual refused to sign.
El Communication barrier prohibited obtaining the acknowledgement.
E1 An emergency situation prevented us from obtaining acknowledgement.
