Medical and Dental Health History Form

Our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only, will never be used to discriminate, and will be kept confidential subject to applicable laws. If you have any questions or are unsure how to answer a question, we’d be happy to assist you - please ask!

First name

Last name

Birthday

Sex

Emergency contact [name, phone, relationship]

Insurance company

Insurance member ID (if present)

Social security number

Name of previous dentist/location

Approximate date of last dental visit

Approximate date of last dental cleaning (if different from above)

Name of family physician | Phone number

DENTAL HEALTH

Select all that apply

MEDICAL HEALTH

Are you ALLERGIC to or had a bad reaction to any of the following (check all that apply):

Are you seeing a PHYSICIAN regularly? If so, what for what condition?

Check off any of the following MEDICAL CONDITIONS that you had or have at the present:

Do you have any disease, condition or problem that WAS NOT LISTED?

The ADA and AHA recommend premedication for patients with the following ONLY. If you have none of the issues and your surgeon recommends antibiotics for life, we have paperwork you can review and we request them to prescribe for you.

Prosthetic heart valve

Prosthetic material for heart valve repair

Heart transplant with valve regurgitation

Unrepaired cyanotic congenital heart disease (including palliative shunts/ conduits)

History of infective endocarditis

Repaired congenital heart defect with residual shunts or valvular regurgitation

I HAVE NONE OF THE ABOVE

FINANCIAL AND CANCELLATION POLICY

Please check each statement once you have reviewed it

1. I understand that my payment portion is due in full on, or before, the date of my appointment

2. I understand that I will need to call to cancel an appointment at least 1 business day in advance so that other patients who need to be seen are not postponed needlessly

3. I understand that a $50 cancellation fee will need to be collected from me before another appointment can be booked if I cancel with less than 1 business day’s notice. [True emergencies will not be subject to the cancellation fee but, if repeatedly missing appointments at the last minute, pre-reserved appointments may not be offered.]

4. If I have multiple last minute cancellations, I understand that time cannot continue to be reserved for me. I may be dismissed as a patient, or can only be booked only same-day, whenever there is availability

5. I authorize payment of dental benefits to myself or the office for professional services rendered and release of any information needed to process my claims

Signature

SOCIAL HISTORY

(Check all that apply)

Do you use any form of tobacco? (cigarettes/cigars, vaping, chewing)

Do you use any kind of recreational drugs: _____________

Do you drink alcohol? How often:________ How many drinks:_____

Are you pregnant? If yes, due date: ___________________

Could you be pregnant?

Are you nursing?

Are you taking hormone replacements? Which one(s): _______________

NONE OF THE ABOVE

Use this space to expand on any checked boxes above:

MEDICATIONS

Prescription, over-the-counter, vitamins, herbs, and supplements: (If there are too many to list, we can make a copy of your medication list to keep with your file) . Type NONE if you are not taking any medications.

MAJOR SURGERIES OR HOSPITAL VISITS

Type and Year: (Type NONE if this does not apply.)

HIPAA ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

I have reviewed a copy of this office’s Notice of Privacy Practices and have had full opportunity to read and consider the contents. I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.

Signature

Note: If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information.

Right to Revoke: You have the right to revoke this consent at any time by giving us written notice of your revocation. Revocation will not affect any action we took in reliance on this consent before we received your revocation. Please understand that revocation may make thorough treatment difficult and we may decline to treat you or to continue treating you if you revoke this consent.

FINAL REVIEW OF FORM

Authorization: I have reviewed the information on this form, understood it, and it is accurate to the best of my knowledge. I understand that this information will be relied upon by the dentist and staff to help determine appropriate and healthful dental treatment. I acknowledge that my questions, if any, about inquiries have been answered to my satisfaction. I will not hold my dentist, or any other member of the staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. If there is any change in my medical status I will inform the dentist.

Signature

THE HILLS DENTAL STUDIO

YOU

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