Loading...

 

Ai-Lien Sperry, D.M.D., P.S.  |  Sperry Dentistry  |  4820 NE 4TH ST. Suite #A-108  |  Renton, WA 98509  |  425.687.2876

 

OUR POLICIES

 

OUR OFFICE POLICY

Our office is committed to providing you with the best quality of dental care.  In order to achieve this goal, we need your cooperation as well as your understanding of this payment policy. Payment for services is due at the time the care is provided, unless other arrangements are made with our Business Manager. For your convenience we offer the following methods of payments:  Cash, Checks, Visa, MasterCard, Discover, and AMEX. A fee of $35.00 will be assessed on any returned check.  A charge of $75.00/hr is made for broken or cancelled appointments without 48 hours notice (excluding weekends and holidays).

I Agree

 

PATIENT RESPONSIBILITIES REGARDING DENTAL INSURANCE

If you have dental insurance, we will gladly submit claims for you; provided we are given complete and accurate insurance information, as well as a release of benefits and information to your insurance company.  We can estimate your insurance benefits for you; however we cannot guarantee payments. These estimates are based on your exams & x-rays. Changes in proposed treatment may need to be made due to clinical considerations. Your dental insurance is a contract between you and your insurance company; it is your responsibility to be aware of annual maximums and contract limitations.  You are responsible for payment for services received from Dr. Sperry in accordance with the office regular fees and terms.  Your responsibility is not modified by whether any third party (insurance) pays for all, part, or none of the charges.

I Agree

 

AUTHORIZATION AND RELEASE

Permit for treatment and/or surgical care: I hereby grant permission to Dr. Sperry, or her assignee, to employ such established treatments and therapy as may be deemed professionally necessary and advisable. 

Financial agreement: All charges for services and treatment will be paid upon completion of appointment. I understand that this account becomes delinquent if not paid within 60 days after billing and that at this time a Finance Charge of 1.5% (18% per annum) per month will be applied on the unpaid balance. In the event of default, I agree to pay all legal indebtedness together with such collection costs if suit be instituted hereunder.  I authorize all credit inquiries deemed necessary in connection with my account. 

Insurance: I hereby authorize payment directly to Dr. Sperry, the dentist, otherwise payable to me.

December 11, 2019

 

HIPAA NOTICE OF PRIVACY PRACTICES

 

OUR LEGAL DUTY

Federal and state law requires us to maintain the privacy of your health information. That law also states we must provide you with this notice regarding our privacy practices, our legal obligations and your rights concerning your personal health information (PHI). We will follow these practices described in this notice until such time it is amended. This notice will take effect on April 14, 2003 and will remain so until we amend it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

 

USES AND DISCLOSURES OF HEALTH INFORMATION

Our office may use and disclose your personal health information for treatment, payment and other healthcare operations in the following manner:

Treatment Information:  Our office may use and disclose your health and insurance information to a referring Dentist, to your Physician and/or any other healthcare provider who is involved in your treatment past, present and future.

Payment of Services Rendered:  Our office may use and disclose your information as you reported on our registration form to obtain payment for services rendered. This may be disclosed to an insurance company, any healthcare provider or entity involved in your treatment and any other agency for the use of collection purposes. These entities will be subject to the Federal Privacy Rules and Regulations.

Healthcare Operations:  Our office may use and disclose your health information for our healthcare operations. We may disclose your health Information to another healthcare provider or organization which you are affiliated with to support their healthcare operations. These entities will be subject to Federal Privacy Rules and Regulations. We may disclose your information to them for their own internal purposes and to detect or prevent healthcare fraud.

Your Authorization:  You may give us written authorization to disclose your information to anyone for any purpose. You may revoke this privilege at anytime in writing. Revocation of your information does not affect information while permission was granted. Unless we have written authorization from you we cannot release information to anyone for any reason unless described in this notice.

Your Family and Associates:  We may disclose your information to family members and associates for the purpose of aiding in your healthcare or payment for services rendered. Before any personal health information is disclosed we will give you an opportunity to decline the use or disclosure of your information. If you are unable to give consent due to absence or emergency, we will use our professional judgment to disclose in your best interest, to include: drug prescriptions, supplies, x-rays and health forms. We may disclose your health information to notify or assist another in your care, location and general condition.

Appointment and Pre-Medication Information:  We may use or disclose information about you for the purpose of reminders for appointments in the form of phone calls at home or work to include voicemail messages, in the form of e-mail or text, in the form of postcards and or letters. We may also use mail and telephone for financial disclosure.

Disaster Policy:  We may use or disclose your health information to any entity, public or private authorized by law in the event of a disaster to assist in relief efforts.

Public Benefit:  We may use or disclose your health information as authorized or required by law if merited to be in the best interest of the public in the following ways:

  • As required by law or Department of Health and Human Services
  • For public health reporting including disease and vital statistics, reporting of child abuse, FDA oversight and to employers in regards to work related illness or injury
  • In the reporting of domestic violence, adult abuse and neglect
  • In response to a court order or other lawful purpose as required
  • To law enforcement officials or other lawful agencies for information pertaining to crimes being investigated, crimes on our premises and for location or identifying a possible suspect in a crime
  • To coroners, funeral directors or medical examiners
  • To avoid serious threat to health or safety
  • If requested for research activities
  • To the military and federal officials for national security
  • To corrections officials regarding inmates
  • And as authorization by Washington Labor and Industries laws

 

​PATIENT RIGHTS

Accessing Your Records:  You have the right to ask to see your records with limited exceptions. The health records we create and store are the property of the practice. The protected health information, however, generally belongs to you. You must make your request in writing. We will have a form available for your use, if you are not to use our form you may mail in your written request as directed at the end of this notice. We will comply or reply within the state and general guidelines. You will be charged a fair and reasonable fee as set forth by state and federal regulations to include copy charges, labor and postage. You may obtain more information on contacting us at the end of this notice.

Disclosure of Information:  You have the right to request a list of instances when our business associates or our office may have used or disclosed your health information. You may request information for 6 years back but not prior to April 14, 2003. If you request information more than 1 time in a 12 month period, a charge as stated will be assessed, not to exceed guidelines set forth by state and federal laws. Treatment, payment, healthcare operations and certain other charted information will be excluded. Please contact us as described below for any questions or requests.

Restrictions of Disclosure:  You have the right to restrict the use or disclosure of your health information in writing. We are not required to accept a request; however, if we do we must follow through with your request, except in emergency. Your request is not binding unless it is in writing.

Alternative Communication:  You have the right to request we contact you in an alternate means or location about your health information. You must make this request in writing and it must not circumvent the way you will pay for your services rendered. Your request must be reasonable and effective in contacting you. Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment:  You have the right to ask us to amend your health information. Your request must be in writing along with an explanation as to why we should amend your information. There are certain circumstances in which we may deny your request. 

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

 

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

 

ACKNOWLEGEMENT OF PRIVACY PRACTICES

 

My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA).  I understand that this information can and will be used to:

  • Provide and coordinate my treatment among a number of health care providers who may be involved in that treatment directly and indirectly
  • Obtain payment from third-party payers for my health care services
  • Conduct normal health care operations such as quality assessment and improvement activities

I have been informed of my dental provider’s Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information.  I have been given the right to review and receive a copy of such Notice of Privacy Practices.  I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices.

I Agree

I am legally authorized to sign on my behalf or on the behalf of the patient as a guardian Relationship to the patient 

I Agree
 

December 11, 2019

First Patient Name

First Name*

Middle Name

Last Name*

Phone*
First Patient Date of Birth*
First Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)
AIDS or HIV
Anemia
Angina
Artificial heart valve
Artificial joints
Arthritis
Asthma
Auto-immune disease
Blood transfusion
Bulimia
Cancer
Cataracts/Glaucoma
Chemical dependency
Chemotherapy
Chronic fatigue syndrome
Convulsions
Depression/anxiety
Diabetes
Dieting concerns
Dizziness
Epilepsy
Emphysema
Fainting
Hay fever
Headaches
Heart attack
Heart disease
Heart murmur
Hemophilia (Bleeding disorder)
Hepatitis A (Infectious)
Hepatitis B (Serum)
Hepatitis C
High blood pressure
Low blood pressure
Jaundice
Kidney disease
Liver disease
Lupus
Mitral valve prolapse
Neurological disorders
Pacemaker / Defibrillator
Psychiatric care
Radiation treatment
Rheumatic / scarlet fever
Sickle cell anemia
Sinus infections
Stroke
Thyroid disorder
Tuberculosis
Ulcer
Venereal disease
None apply

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Are you allergic to or have you had a reaction to any of the following: Local anesthetic (Novocaine), Penicillin or other antibiotics, sulfa drugs, sedatives, iodine, Aspirin, codeine, or other medications:*
No
Yes
Women only: Are you taking contraceptives, are nursing, or think you may be pregnant?*
No
Yes
Have you ever had excessive bleeding following an injury?*
No
Yes
Do you smoke or use tobacco products?*
No
Yes
Have you ever been hospitalized for any surgical operations or serious illness?*
No
Yes
Are you under medical treatment now?*
No
Yes
Are you taking any of the following herbal medicine or natural supplements: Appetite suppressants, diet supplements, garlic, Ginkgo Biloba, ginseng, Motrin/Advil (Ibuprofen), St. Johns Wart*
No
Yes
Are you taking or have you ever taken Biophosphonates for osteoporosis & cancer, or the following medications: Fosamax, Boniva, Actnel, Zometa, Aredia, Ostac, Skelid, Didronel, or other*
No
Yes
First Patient Signature*
Second Patient Name

First Name*

Middle Name

Last Name*
Second Patient Date of Birth*
Second Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)
AIDS or HIV
Anemia
Angina
Artificial heart valve
Artificial joints
Arthritis
Asthma
Auto-immune disease
Blood transfusion
Bulimia
Cancer
Cataracts/Glaucoma
Chemical dependency
Chemotherapy
Chronic fatigue syndrome
Convulsions
Depression/anxiety
Diabetes
Dieting concerns
Dizziness
Epilepsy
Emphysema
Fainting
Hay fever
Headaches
Heart attack
Heart disease
Heart murmur
Hemophilia (Bleeding disorder)
Hepatitis A (Infectious)
Hepatitis B (Serum)
Hepatitis C
High blood pressure
Low blood pressure
Jaundice
Kidney disease
Liver disease
Lupus
Mitral valve prolapse
Neurological disorders
Pacemaker / Defibrillator
Psychiatric care
Radiation treatment
Rheumatic / scarlet fever
Sickle cell anemia
Sinus infections
Stroke
Thyroid disorder
Tuberculosis
Ulcer
Venereal disease
None apply

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Are you allergic to or have you had a reaction to any of the following: Local anesthetic (Novocaine), Penicillin or other antibiotics, sulfa drugs, sedatives, iodine, Aspirin, codeine, or other medications:*
No
Yes
Women only: Are you taking contraceptives, are nursing, or think you may be pregnant?*
No
Yes
Have you ever had excessive bleeding following an injury?*
No
Yes
Do you smoke or use tobacco products?*
No
Yes
Have you ever been hospitalized for any surgical operations or serious illness?*
No
Yes
Are you under medical treatment now?*
No
Yes
Are you taking any of the following herbal medicine or natural supplements: Appetite suppressants, diet supplements, garlic, Ginkgo Biloba, ginseng, Motrin/Advil (Ibuprofen), St. Johns Wart*
No
Yes
Are you taking or have you ever taken Biophosphonates for osteoporosis & cancer, or the following medications: Fosamax, Boniva, Actnel, Zometa, Aredia, Ostac, Skelid, Didronel, or other*
No
Yes
Third Patient Name

First Name*

Middle Name

Last Name*
Third Patient Date of Birth*
Third Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)
AIDS or HIV
Anemia
Angina
Artificial heart valve
Artificial joints
Arthritis
Asthma
Auto-immune disease
Blood transfusion
Bulimia
Cancer
Cataracts/Glaucoma
Chemical dependency
Chemotherapy
Chronic fatigue syndrome
Convulsions
Depression/anxiety
Diabetes
Dieting concerns
Dizziness
Epilepsy
Emphysema
Fainting
Hay fever
Headaches
Heart attack
Heart disease
Heart murmur
Hemophilia (Bleeding disorder)
Hepatitis A (Infectious)
Hepatitis B (Serum)
Hepatitis C
High blood pressure
Low blood pressure
Jaundice
Kidney disease
Liver disease
Lupus
Mitral valve prolapse
Neurological disorders
Pacemaker / Defibrillator
Psychiatric care
Radiation treatment
Rheumatic / scarlet fever
Sickle cell anemia
Sinus infections
Stroke
Thyroid disorder
Tuberculosis
Ulcer
Venereal disease
None apply

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Are you allergic to or have you had a reaction to any of the following: Local anesthetic (Novocaine), Penicillin or other antibiotics, sulfa drugs, sedatives, iodine, Aspirin, codeine, or other medications:*
No
Yes
Women only: Are you taking contraceptives, are nursing, or think you may be pregnant?*
No
Yes
Have you ever had excessive bleeding following an injury?*
No
Yes
Do you smoke or use tobacco products?*
No
Yes
Have you ever been hospitalized for any surgical operations or serious illness?*
No
Yes
Are you under medical treatment now?*
No
Yes
Are you taking any of the following herbal medicine or natural supplements: Appetite suppressants, diet supplements, garlic, Ginkgo Biloba, ginseng, Motrin/Advil (Ibuprofen), St. Johns Wart*
No
Yes
Are you taking or have you ever taken Biophosphonates for osteoporosis & cancer, or the following medications: Fosamax, Boniva, Actnel, Zometa, Aredia, Ostac, Skelid, Didronel, or other*
No
Yes
Fourth Patient Name

First Name*

Middle Name

Last Name*
Fourth Patient Date of Birth*
Fourth Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)
AIDS or HIV
Anemia
Angina
Artificial heart valve
Artificial joints
Arthritis
Asthma
Auto-immune disease
Blood transfusion
Bulimia
Cancer
Cataracts/Glaucoma
Chemical dependency
Chemotherapy
Chronic fatigue syndrome
Convulsions
Depression/anxiety
Diabetes
Dieting concerns
Dizziness
Epilepsy
Emphysema
Fainting
Hay fever
Headaches
Heart attack
Heart disease
Heart murmur
Hemophilia (Bleeding disorder)
Hepatitis A (Infectious)
Hepatitis B (Serum)
Hepatitis C
High blood pressure
Low blood pressure
Jaundice
Kidney disease
Liver disease
Lupus
Mitral valve prolapse
Neurological disorders
Pacemaker / Defibrillator
Psychiatric care
Radiation treatment
Rheumatic / scarlet fever
Sickle cell anemia
Sinus infections
Stroke
Thyroid disorder
Tuberculosis
Ulcer
Venereal disease
None apply

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Are you allergic to or have you had a reaction to any of the following: Local anesthetic (Novocaine), Penicillin or other antibiotics, sulfa drugs, sedatives, iodine, Aspirin, codeine, or other medications:*
No
Yes
Women only: Are you taking contraceptives, are nursing, or think you may be pregnant?*
No
Yes
Have you ever had excessive bleeding following an injury?*
No
Yes
Do you smoke or use tobacco products?*
No
Yes
Have you ever been hospitalized for any surgical operations or serious illness?*
No
Yes
Are you under medical treatment now?*
No
Yes
Are you taking any of the following herbal medicine or natural supplements: Appetite suppressants, diet supplements, garlic, Ginkgo Biloba, ginseng, Motrin/Advil (Ibuprofen), St. Johns Wart*
No
Yes
Are you taking or have you ever taken Biophosphonates for osteoporosis & cancer, or the following medications: Fosamax, Boniva, Actnel, Zometa, Aredia, Ostac, Skelid, Didronel, or other*
No
Yes
Fifth Patient Name

First Name*

Middle Name

Last Name*
Fifth Patient Date of Birth*
Fifth Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)
AIDS or HIV
Anemia
Angina
Artificial heart valve
Artificial joints
Arthritis
Asthma
Auto-immune disease
Blood transfusion
Bulimia
Cancer
Cataracts/Glaucoma
Chemical dependency
Chemotherapy
Chronic fatigue syndrome
Convulsions
Depression/anxiety
Diabetes
Dieting concerns
Dizziness
Epilepsy
Emphysema
Fainting
Hay fever
Headaches
Heart attack
Heart disease
Heart murmur
Hemophilia (Bleeding disorder)
Hepatitis A (Infectious)
Hepatitis B (Serum)
Hepatitis C
High blood pressure
Low blood pressure
Jaundice
Kidney disease
Liver disease
Lupus
Mitral valve prolapse
Neurological disorders
Pacemaker / Defibrillator
Psychiatric care
Radiation treatment
Rheumatic / scarlet fever
Sickle cell anemia
Sinus infections
Stroke
Thyroid disorder
Tuberculosis
Ulcer
Venereal disease
None apply

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Are you allergic to or have you had a reaction to any of the following: Local anesthetic (Novocaine), Penicillin or other antibiotics, sulfa drugs, sedatives, iodine, Aspirin, codeine, or other medications:*
No
Yes
Women only: Are you taking contraceptives, are nursing, or think you may be pregnant?*
No
Yes
Have you ever had excessive bleeding following an injury?*
No
Yes
Do you smoke or use tobacco products?*
No
Yes
Have you ever been hospitalized for any surgical operations or serious illness?*
No
Yes
Are you under medical treatment now?*
No
Yes
Are you taking any of the following herbal medicine or natural supplements: Appetite suppressants, diet supplements, garlic, Ginkgo Biloba, ginseng, Motrin/Advil (Ibuprofen), St. Johns Wart*
No
Yes
Are you taking or have you ever taken Biophosphonates for osteoporosis & cancer, or the following medications: Fosamax, Boniva, Actnel, Zometa, Aredia, Ostac, Skelid, Didronel, or other*
No
Yes
Sixth Patient Name

First Name*

Middle Name

Last Name*
Sixth Patient Date of Birth*
Sixth Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)
AIDS or HIV
Anemia
Angina
Artificial heart valve
Artificial joints
Arthritis
Asthma
Auto-immune disease
Blood transfusion
Bulimia
Cancer
Cataracts/Glaucoma
Chemical dependency
Chemotherapy
Chronic fatigue syndrome
Convulsions
Depression/anxiety
Diabetes
Dieting concerns
Dizziness
Epilepsy
Emphysema
Fainting
Hay fever
Headaches
Heart attack
Heart disease
Heart murmur
Hemophilia (Bleeding disorder)
Hepatitis A (Infectious)
Hepatitis B (Serum)
Hepatitis C
High blood pressure
Low blood pressure
Jaundice
Kidney disease
Liver disease
Lupus
Mitral valve prolapse
Neurological disorders
Pacemaker / Defibrillator
Psychiatric care
Radiation treatment
Rheumatic / scarlet fever
Sickle cell anemia
Sinus infections
Stroke
Thyroid disorder
Tuberculosis
Ulcer
Venereal disease
None apply

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Are you allergic to or have you had a reaction to any of the following: Local anesthetic (Novocaine), Penicillin or other antibiotics, sulfa drugs, sedatives, iodine, Aspirin, codeine, or other medications:*
No
Yes
Women only: Are you taking contraceptives, are nursing, or think you may be pregnant?*
No
Yes
Have you ever had excessive bleeding following an injury?*
No
Yes
Do you smoke or use tobacco products?*
No
Yes
Have you ever been hospitalized for any surgical operations or serious illness?*
No
Yes
Are you under medical treatment now?*
No
Yes
Are you taking any of the following herbal medicine or natural supplements: Appetite suppressants, diet supplements, garlic, Ginkgo Biloba, ginseng, Motrin/Advil (Ibuprofen), St. Johns Wart*
No
Yes
Are you taking or have you ever taken Biophosphonates for osteoporosis & cancer, or the following medications: Fosamax, Boniva, Actnel, Zometa, Aredia, Ostac, Skelid, Didronel, or other*
No
Yes
Seventh Patient Name

First Name*

Middle Name

Last Name*
Seventh Patient Date of Birth*
Seventh Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)
AIDS or HIV
Anemia
Angina
Artificial heart valve
Artificial joints
Arthritis
Asthma
Auto-immune disease
Blood transfusion
Bulimia
Cancer
Cataracts/Glaucoma
Chemical dependency
Chemotherapy
Chronic fatigue syndrome
Convulsions
Depression/anxiety
Diabetes
Dieting concerns
Dizziness
Epilepsy
Emphysema
Fainting
Hay fever
Headaches
Heart attack
Heart disease
Heart murmur
Hemophilia (Bleeding disorder)
Hepatitis A (Infectious)
Hepatitis B (Serum)
Hepatitis C
High blood pressure
Low blood pressure
Jaundice
Kidney disease
Liver disease
Lupus
Mitral valve prolapse
Neurological disorders
Pacemaker / Defibrillator
Psychiatric care
Radiation treatment
Rheumatic / scarlet fever
Sickle cell anemia
Sinus infections
Stroke
Thyroid disorder
Tuberculosis
Ulcer
Venereal disease
None apply

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Are you allergic to or have you had a reaction to any of the following: Local anesthetic (Novocaine), Penicillin or other antibiotics, sulfa drugs, sedatives, iodine, Aspirin, codeine, or other medications:*
No
Yes
Women only: Are you taking contraceptives, are nursing, or think you may be pregnant?*
No
Yes
Have you ever had excessive bleeding following an injury?*
No
Yes
Do you smoke or use tobacco products?*
No
Yes
Have you ever been hospitalized for any surgical operations or serious illness?*
No
Yes
Are you under medical treatment now?*
No
Yes
Are you taking any of the following herbal medicine or natural supplements: Appetite suppressants, diet supplements, garlic, Ginkgo Biloba, ginseng, Motrin/Advil (Ibuprofen), St. Johns Wart*
No
Yes
Are you taking or have you ever taken Biophosphonates for osteoporosis & cancer, or the following medications: Fosamax, Boniva, Actnel, Zometa, Aredia, Ostac, Skelid, Didronel, or other*
No
Yes
Eighth Patient Name

First Name*

Middle Name

Last Name*
Eighth Patient Date of Birth*
Eighth Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)
AIDS or HIV
Anemia
Angina
Artificial heart valve
Artificial joints
Arthritis
Asthma
Auto-immune disease
Blood transfusion
Bulimia
Cancer
Cataracts/Glaucoma
Chemical dependency
Chemotherapy
Chronic fatigue syndrome
Convulsions
Depression/anxiety
Diabetes
Dieting concerns
Dizziness
Epilepsy
Emphysema
Fainting
Hay fever
Headaches
Heart attack
Heart disease
Heart murmur
Hemophilia (Bleeding disorder)
Hepatitis A (Infectious)
Hepatitis B (Serum)
Hepatitis C
High blood pressure
Low blood pressure
Jaundice
Kidney disease
Liver disease
Lupus
Mitral valve prolapse
Neurological disorders
Pacemaker / Defibrillator
Psychiatric care
Radiation treatment
Rheumatic / scarlet fever
Sickle cell anemia
Sinus infections
Stroke
Thyroid disorder
Tuberculosis
Ulcer
Venereal disease
None apply

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Are you allergic to or have you had a reaction to any of the following: Local anesthetic (Novocaine), Penicillin or other antibiotics, sulfa drugs, sedatives, iodine, Aspirin, codeine, or other medications:*
No
Yes
Women only: Are you taking contraceptives, are nursing, or think you may be pregnant?*
No
Yes
Have you ever had excessive bleeding following an injury?*
No
Yes
Do you smoke or use tobacco products?*
No
Yes
Have you ever been hospitalized for any surgical operations or serious illness?*
No
Yes
Are you under medical treatment now?*
No
Yes
Are you taking any of the following herbal medicine or natural supplements: Appetite suppressants, diet supplements, garlic, Ginkgo Biloba, ginseng, Motrin/Advil (Ibuprofen), St. Johns Wart*
No
Yes
Are you taking or have you ever taken Biophosphonates for osteoporosis & cancer, or the following medications: Fosamax, Boniva, Actnel, Zometa, Aredia, Ostac, Skelid, Didronel, or other*
No
Yes
Ninth Patient Name

First Name*

Middle Name

Last Name*
Ninth Patient Date of Birth*
Ninth Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)
AIDS or HIV
Anemia
Angina
Artificial heart valve
Artificial joints
Arthritis
Asthma
Auto-immune disease
Blood transfusion
Bulimia
Cancer
Cataracts/Glaucoma
Chemical dependency
Chemotherapy
Chronic fatigue syndrome
Convulsions
Depression/anxiety
Diabetes
Dieting concerns
Dizziness
Epilepsy
Emphysema
Fainting
Hay fever
Headaches
Heart attack
Heart disease
Heart murmur
Hemophilia (Bleeding disorder)
Hepatitis A (Infectious)
Hepatitis B (Serum)
Hepatitis C
High blood pressure
Low blood pressure
Jaundice
Kidney disease
Liver disease
Lupus
Mitral valve prolapse
Neurological disorders
Pacemaker / Defibrillator
Psychiatric care
Radiation treatment
Rheumatic / scarlet fever
Sickle cell anemia
Sinus infections
Stroke
Thyroid disorder
Tuberculosis
Ulcer
Venereal disease
None apply

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Are you allergic to or have you had a reaction to any of the following: Local anesthetic (Novocaine), Penicillin or other antibiotics, sulfa drugs, sedatives, iodine, Aspirin, codeine, or other medications:*
No
Yes
Women only: Are you taking contraceptives, are nursing, or think you may be pregnant?*
No
Yes
Have you ever had excessive bleeding following an injury?*
No
Yes
Do you smoke or use tobacco products?*
No
Yes
Have you ever been hospitalized for any surgical operations or serious illness?*
No
Yes
Are you under medical treatment now?*
No
Yes
Are you taking any of the following herbal medicine or natural supplements: Appetite suppressants, diet supplements, garlic, Ginkgo Biloba, ginseng, Motrin/Advil (Ibuprofen), St. Johns Wart*
No
Yes
Are you taking or have you ever taken Biophosphonates for osteoporosis & cancer, or the following medications: Fosamax, Boniva, Actnel, Zometa, Aredia, Ostac, Skelid, Didronel, or other*
No
Yes
Tenth Patient Name

First Name*

Middle Name

Last Name*
Tenth Patient Date of Birth*
Tenth Patient Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)
AIDS or HIV
Anemia
Angina
Artificial heart valve
Artificial joints
Arthritis
Asthma
Auto-immune disease
Blood transfusion
Bulimia
Cancer
Cataracts/Glaucoma
Chemical dependency
Chemotherapy
Chronic fatigue syndrome
Convulsions
Depression/anxiety
Diabetes
Dieting concerns
Dizziness
Epilepsy
Emphysema
Fainting
Hay fever
Headaches
Heart attack
Heart disease
Heart murmur
Hemophilia (Bleeding disorder)
Hepatitis A (Infectious)
Hepatitis B (Serum)
Hepatitis C
High blood pressure
Low blood pressure
Jaundice
Kidney disease
Liver disease
Lupus
Mitral valve prolapse
Neurological disorders
Pacemaker / Defibrillator
Psychiatric care
Radiation treatment
Rheumatic / scarlet fever
Sickle cell anemia
Sinus infections
Stroke
Thyroid disorder
Tuberculosis
Ulcer
Venereal disease
None apply

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Are you allergic to or have you had a reaction to any of the following: Local anesthetic (Novocaine), Penicillin or other antibiotics, sulfa drugs, sedatives, iodine, Aspirin, codeine, or other medications:*
No
Yes
Women only: Are you taking contraceptives, are nursing, or think you may be pregnant?*
No
Yes
Have you ever had excessive bleeding following an injury?*
No
Yes
Do you smoke or use tobacco products?*
No
Yes
Have you ever been hospitalized for any surgical operations or serious illness?*
No
Yes
Are you under medical treatment now?*
No
Yes
Are you taking any of the following herbal medicine or natural supplements: Appetite suppressants, diet supplements, garlic, Ginkgo Biloba, ginseng, Motrin/Advil (Ibuprofen), St. Johns Wart*
No
Yes
Are you taking or have you ever taken Biophosphonates for osteoporosis & cancer, or the following medications: Fosamax, Boniva, Actnel, Zometa, Aredia, Ostac, Skelid, Didronel, or other*
No
Yes
Parent or Guardian's Email Address

Email
Check to receive dental insights, patient offers, and exclusive discounts by e-mail.
A signed copy of this waiver will be sent to the email address you provide.
Emergency Contact

Emergency Contact's Name*

Emergency Contact's Phone Number*
Parent or Guardian's Driver's License / ID Card

Driver's License / ID Card Number*

Issuing State*
Insurance Information

Dental Insurance Provider *

Insurance Provider Participant ID # *

Secondary Insurance Provider

Secondary Insurance Provider Participant ID #
Credit card on file (optional)

Card Number

Full Name

Expiration Date

Security Code

Zip Code
Parent(s) or court-appointed legal guardian(s) must sign for any participating minor (those under 18 years of age) and agree that they and the minor are subject to all the terms of this document, as set forth above.
Parent or Guardian's Name

First Name*

Middle Name

Last Name*

Phone*
Parent or Guardian's Date of Birth*
Parent or Guardian's Information & History

Home address (Street, City, State, Zip) *

Billing address (Street, City, State, Zip) *

SSN# *

Employer, Employer phone number

DENTAL HISTORY


Name of last dentist, Month/Year of last exam

Have you ever had a reaction to Novocain or Anesthesia? If yes, when? *

Do you require pre-medications prior to dental treatment due to joint replacement, artificial heart valve, or endocarditis? *

Chief complaint (reason for today's visit)
Dental History (Please check all that apply)
Accidental injury to teeth/mouth
Allergy to latex
Allergy to nitrous oxide
Bleeding gums
Clench/grind teeth
Diagnosed with TMJ/TMD
Earaches
Enamel erosion
Gum/bone recession
Jaw pain/discomfort
Loose teeth/fillings
Oral sores/infection
Orthodontic treatment
Periodontal treatment
Sensitive to biting/chewing
Sensitive to hot/cold
Sensitive to sweet/sour
Sleep apnea
Smoke/chew tobacco
Staining
Swollen face/cheek
Swollen/tender gums
Swollen lymph nodes
Tooth discoloration
Toothache/pain
Wear dentures/appliances

MEDICAL HISTORY

Have you had any of the following? (Check all that apply)
AIDS or HIV
Anemia
Angina
Artificial heart valve
Artificial joints
Arthritis
Asthma
Auto-immune disease
Blood transfusion
Bulimia
Cancer
Cataracts/Glaucoma
Chemical dependency
Chemotherapy
Chronic fatigue syndrome
Convulsions
Depression/anxiety
Diabetes
Dieting concerns
Dizziness
Epilepsy
Emphysema
Fainting
Hay fever
Headaches
Heart attack
Heart disease
Heart murmur
Hemophilia (Bleeding disorder)
Hepatitis A (Infectious)
Hepatitis B (Serum)
Hepatitis C
High blood pressure
Low blood pressure
Jaundice
Kidney disease
Liver disease
Lupus
Mitral valve prolapse
Neurological disorders
Pacemaker / Defibrillator
Psychiatric care
Radiation treatment
Rheumatic / scarlet fever
Sickle cell anemia
Sinus infections
Stroke
Thyroid disorder
Tuberculosis
Ulcer
Venereal disease
None apply

Are there any disease, condition, or problems not listed previously that should be mentioned? *

Please list all medications you are currently taking (or write "none"). You may also bring a list of your medications to the office on your first visit. *
Are you allergic to or have you had a reaction to any of the following: Local anesthetic (Novocaine), Penicillin or other antibiotics, sulfa drugs, sedatives, iodine, Aspirin, codeine, or other medications:*
No
Yes
Women only: Are you taking contraceptives, are nursing, or think you may be pregnant?*
No
Yes
Have you ever had excessive bleeding following an injury?*
No
Yes
Do you smoke or use tobacco products?*
No
Yes
Have you ever been hospitalized for any surgical operations or serious illness?*
No
Yes
Are you under medical treatment now?*
No
Yes
Are you taking any of the following herbal medicine or natural supplements: Appetite suppressants, diet supplements, garlic, Ginkgo Biloba, ginseng, Motrin/Advil (Ibuprofen), St. Johns Wart*
No
Yes
Are you taking or have you ever taken Biophosphonates for osteoporosis & cancer, or the following medications: Fosamax, Boniva, Actnel, Zometa, Aredia, Ostac, Skelid, Didronel, or other*
No
Yes
Parent or Guardian's Signature*
Electronic Signature Consent*
By checking here, you are consenting to the use of your electronic signature in lieu of an original signature on paper. You have the right to request that you sign a paper copy instead. By checking here, you are waiving that right. After consent, you may, upon written request to us, obtain a paper copy of an electronic record. No fee will be charged for such copy and no special hardware or software is required to view it. Your agreement to use an electronic signature with us for any documents will continue until such time as you notify us in writing that you no longer wish to use an electronic signature. There is no penalty for withdrawing your consent. You should always make sure that we have a current email address in order to contact you regarding any changes, if necessary.


One or more problems exist. Please scroll up.




Powered by  Smartwaiver