Sitwell Dental New Patient Form

New Patients
Name
Date
Date of Birth

MonthDayYear
Date
Gender

MaleFemale
Contact Information
Address
City
State
Zip Code
Phone Number
Alternate Number
Email
example@example.com
Emergency Contact
Name
Phone Number
Relationship
Dental Insurance
Primary
Policy Holder/ DOB
Insurance ID #
Insurance Company Phone Number
Secondary
Policy Holder/ DOB
Previous Dentist
Name
Phone Number
Address
City/State
Zip
Pharmacy
Name
Phone Number
Address
City/State
Zip
Medical History
Active tuberculosis

yesno
Persistent cough greater than a 3 week duration

yesno
Cough that produces blood

yesno
Been exposed to anyone with tuberculosis

yesno
Are you now under the care of a physician?

yesno
Physician Name:
Physician's Phone Number:
Address:
Are You In Good Health?

yesno
Has there been any change in your general health within the past year?

yesno
If yes, what condition is being treated:
Date of last physical exam:
Have you had a serious illness, operation or been hospitalized in the past 5 years?

yesno
If yes, what condition is being treated:
Are you taking or have you recently taken any prescription or over the counter medicine(s)?

yesno
If so, please list all, including vitamins, natural or herbal preparations and/or diet supplements:
Do you wear contact lenses?

yesno
JOINT REPLACEMENT:
Have you had any orthopedic total joint (hip, knee, elbow, finger) replacement?

yesno
Date:
If yes, have you had any complication:
Are you taking or scheduled to begin taking either of the medications, alendronate (Fosamax) or risedronate (Actonel) for osteoporosis or Paget’s disease?

yesno
Since 2001, were you treated or are you presently scheduled to begin treatment with the intravenous biphosphonates (Aredia or Zometa) for bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?

yesno
Date treatment began:

MonthDayYear
Date
Do you use controlled substances (drugs)?

yesno
Do you use tobacco (smoking/chew)?

yesno
Do you drink alcoholic beverages?

yesno
If yes, how much alcohol did you drink in the last 24 hours:
If yes, how much do you typically drink in a week:
WOMEN ONLY, Are you:
Pregnant

yesno
Number of weeks
Taking birth control pills or hormones:

yesno
Nursing

yesno
Allergies, Are you allergic to or have you have any reaction to:
Local Anesthetics

yesno
Metals

yesno
Aspirin

yesno
Latex

yesno
Penicillin

yesno
Iodine

yesno
Other Antibiotic
Hay fever/seasonal

yesno
Barbiturates/sedatives/sleeping pills

yesno
Animals

yesno
Sulfa

yesno
Food

yesno
Codeine or other narcotics

yesno
Other:
CHD:
Artificial (prosthetic) heart valve

yesno
Unrepaired, cyanotic CHD

yesno
Previous infective endocarditis

yesno
Repaired (completely)

yesno
Damaged valves in transplanted heart

yesno
in the last 6 months

yesno
Congenital heart disease (CHD)

yesno
Repaired CHD with residual defects

yesno
PRESENT CONDITIONS:
Cardiovascular disease

yesno
Chest pain upon exertion

yesno
Angina

yesno
Chronic pain

yesno
Arteriosclerosis

yesno
Diabetes type I or II

yesno
Congestive Heart Failure

yesno
Eating disorder

yesno
Damaged Heart Valves

yesno
Malnutrition

yesno
Heart attack

yesno
Gastrointestinal disease

yesno
Heart murmur

yesno
G.E. Reflux/persistent

yesno
Low blood pressure

yesno
heartburn

yesno
High blood pressure

yesno
Thyroid problems

yesno
Other congenital heart defects

yesno
Stroke

yesno
Mitral valve prolapsed

yesno
Glaucoma

yesno
Pacemaker

yesno
Hepatitis, jaundice or liver disease

yesno
Rheumatic fever

yesno
Epilepsy

yesno
Rheumatic heart disease

yesno
Abnormal bleeding

yesno
Fainting spells or seizures

yesno
Anemia

yesno
Neurological disorders

yesno
Blood transfusion

yesno
Sleep disorder

yesno
Hemophilia

yesno
Mental health disorders

yesno
AIDS or HIV

yesno
Recurrent infections

yesno
Arthritis

yesno
Kidney problems

yesno
Autoimmune disease

yesno
Night sweats

yesno
Rheumatiod Arthritis

yesno
Osteoporosis

yesno
Systemic lupus erythematosus

yesno
Persistent swollen glands in neck

yesno
Asthma

yesno
Severe headaches/migraines

yesno
Bronchitis

yesno
Severe or rapid weight loss

yesno
Emphysema

yesno
Sexually transmitted disease

yesno
Sinus trouble

yesno
Excessive urination

yesno
Tuberculosis

yesno
Cancer/chemotherapy/Radiation

yesno
Do you have any disease, condition, or problem not listed above

yesno
that you think I should know about? Please explain:
PREMEDICATION
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

yesno
Name of physician/dentist (include phone number):
Signature of Patient/Legal Guardian

Clear
Date of Signature

MonthDayYear
Date
Patient Consent Form
- I hereby authorize the dentist and/or the associates, assistants, or dental hygienists to take x-rays, impressions, study models, and other diagnostic aids deem appropriate by the dentist to make a thorough diagnosis of the above patient’s dental needs.
- I authorize the dentist to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
- I consent to the administration of anesthetics and other medications as may be considered necessary and advisable by the dentist. I understand that there are risks and benefits that may occur and are possible in the performance. I can ask for an explanation of possible risks and benefits.
- I give consent to the dentist’s or designated staff’s use and disclosure or any oral, written, or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations.
- I acknowledge that I am responsible and hereby agree to pay for services provided to me or my dependents by Sitwell Dental. I understand that payment or co-payment is due at the same time of services, unless other arrangements have been made,
Patient signature (or authorized person to consent for patient)

Clear
relationship to patient
Witness Signature

Clear
Date

MonthDayYear
Date
HIPAA Consent Form
I understand that under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be
used to:
- Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who maybe involved in that treatment directly and indirectly.
- Obtain payment from third-party payers.
- Conduct normal healthcare operations such as quality assessments and physician certifications.
I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have already taken action in reliance thereon.
Patient/Patient Representative Signature

Clear
Patient Name (Print)
Relationship to Patient
Date

MonthDayYear
Date
Should be Empty:

New Patients

Contact Information

Emergency Contact

Dental Insurance

Previous Dentist

Pharmacy

Medical History

Patient Consent Form

HIPAA Consent Form