Healthcare Oral Health Form

HEALTHCARE ORAL HEALTH FORM

Patient Information

Date of Birth:    Gender: Male Female Other / Prefer not to say

Emergency Contact

Insurance Information

Medical & Dental History

Current Medications (include dosage):

Allergies (medication, latex, food, other):

Do you have any of the following conditions? (check all that apply)

Diabetes    Heart disease    High blood pressure    Bleeding disorder    Asthma    Immunosuppression

Oral Health History

Last dental visit:    Previous dentist:

Do you experience: No pain Intermittent pain Constant pain

Tooth sensitivity to hot/cold/sweets: Yes No    Bleeding gums: Yes No

Tobacco use: Current Former Never    Alcohol use: Yes No

Clenching/grinding    Thumb/finger sucking    Oral piercings    Other:

Treatment Consent and Acknowledgment

I authorize the dentist and staff to perform diagnostic, therapeutic, and operative procedures as may be necessary for proper dental care. Procedures may include radiographs (x-rays), local anesthesia, routine restorative procedures, extractions, endodontic therapy, periodontal therapy, and other procedures as recommended. I understand that all procedures carry inherent risks which may include, but are not limited to, infection, allergic reaction, nerve injury, bleeding, swelling, discomfort, failure of treatment, need for additional treatment, and adverse reactions to medications or anesthesia.

I acknowledge that the dentist has explained the nature of the recommended treatment, the expected benefits, the material risks and complications, and reasonable alternatives, including the option of no treatment. I have had the opportunity to ask questions and have received answers to my satisfaction. I understand I may withdraw consent at any time prior to treatment without affecting my future care.

Consent for radiographs and clinical photographs: I consent to necessary radiographs and photographs for diagnosis, treatment planning, and evaluation. I understand such images will become part of my confidential medical record and may be used for consultation, referral, or education within the treating practice.

I authorize the administration of local anesthetic, and where clinically indicated, the administration of emergency measures. I understand that anesthetic agents and other medications have associated risks.

By signing below I certify that the information I have provided on this form is true and complete to the best of my knowledge, and I consent to the treatment described above.

HIPAA & Release Authorization

I acknowledge receipt of the practice's Notice of Privacy Practices and understand my rights regarding the privacy of my health information. I authorize the release of my dental and medical information to insurance carriers and other providers as necessary for treatment, payment, and healthcare operations. I authorize payment of insurance benefits directly to the treating practice when applicable.

Authorization to release records: Yes    No    Assignment of insurance benefits: Yes    No

Financial Responsibility

I understand I am financially responsible for all charges for services rendered. Insurance is considered a method of reimbursing the patient for fees paid to the provider; therefore, I am responsible for payment of all charges regardless of insurance coverage. I agree to pay any deductible, co-payment, co-insurance, or amounts not covered by insurance. I agree to notify the practice promptly of any changes to insurance coverage.

Cancellation and no-show policy: I understand that missed appointments and late cancellations may incur a fee. Estimated treatment fees will be provided when appropriate; estimates are not guarantees of coverage.

Interpreter / Special Assistance

Interpreter required: Yes No

Patient Certification

I certify that I have read and understand the information on this form. I have disclosed all known medical and dental history. I understand that withholding information may be detrimental to my diagnosis and treatment. I consent to the treatments and authorizations indicated above and accept financial responsibility as stated.

Sign Now