willhitefamilydentistry.com-Patient & family dentistry

WILLHITE FAMILY DENTISTRY

Notice of Privacy Practices Acknowledgement of Receipt Form
Personal Representative(If applicable)
I hereby acknowledge I have received а сору of the Notice of Privacy Practices for WILLHITE FAMILY DENTISTRY.
Patient signature

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Today's Date

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Personal representative's signature

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Today's Date

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TO BE COMPLETED BY MEDICAL FACILITY IF UNABLE TO OBTAIN WRITTEN ACKNOWLEDGEMENT FROM THE PATIENT.
Date

Month Day Year
Date
On {date110} I made a good faith effort to obtain written acknowledgement of receipt of the Notice of Privacy Practices from the above named patient, but was unable to do so becouse of the following reason(s).
Patient (or personal representative) declined to sign the Written Acknowledgement form. Patient (or personal representative) did not understand the request to sign the Written Acknowledgement form.
Other (Specify)
Employee signature

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Date

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Employee job title
Should be Empty:

	Yes	No
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Do you take, or have you taken, Phen-Fan or Redux?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?

	Yes	No
Pregnant /Trying to get pregnant?
Taking oral contraceptives?
Nursing?

	Pre-Appointment	In-Office
1. Do you/they have/had a fever in the past 14 days?
2. Shortness of breath or other difficult ies breathing?
3. Cough?
4. Other flu-like symptoms (nausea, headache, etc.) ?
5. Recent lo ss of taste or smell?
6. Are you/they in contact with any con firmed COVID-19 pts. in the past 3 days?
7. Heart disease, lung disease, kidney disease or other auto-immune disorders?
8. Have you/they traveled out of the country in the past 14 days?

Patient Information