Patient Forms

Dental Health PC & Complete Dental Health LLC

Health History

(Confidential)

(Please fill out all of the forms)

General Information

Todays Date

Date

Email

example@example.com

Name

Last Name First Name Middle Name

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Home Phone

Please enter a valid phone number.

Work Phone

Please enter a valid phone number.

EXT

Employer

Cell Phone

Please enter a valid phone number.

Date of Birth

Date

Age

SSN

Drivers License #

Whom may we thank for referring you?

When and Where are the best times to reach you?

Physicians Name

Ph #

Emergency Contact Person

Ph #

Person Responsible for Account if other than yourself

Name

Relation

Home Phone

Work Phone

Billing Address

Street/ P.O Box

Street Address Line 2

City State / Province

Postal / Zip Code

Insurance Information: If yes please show your new card to a front office member.

Yes No

Primary Insurance

Employer

Insurance Co. Name

Phone Number

Please enter a valid phone number.

Group #

Insured's Name

ID /SSN

Birthdate

Date

Relation

Secondary Insurance

Employer

Insurance Co. Name

Phone#

Group #

Insured's Name

ID/SSN

Birthdate

Date

Relation

Dental History

Are you currently in pain?

Yes No

If yes , Where ?

Have you ever been told you have gum disease?

Yes No

Have you ever been treated for gum disease?

Yes No

Do you have any growth/swelling in your mouth?

Yes No

Are your teeth sensitive to : Heat, Cold, Sweets, Pressure from biting or chewing?

Yes No

If yes , Where ?

Have you experienced Problems associated with any previous dental work?

Yes No

If yes , Explain

Do you require antibiotics before dental treatment?

Yes No

Have you had braces(orthodontics)?

Yes No

Do you still have wisdom teeth?

Yes No

Do you have frequent cold sores, canker sores, fever blisters on your gums, cheeks, lips?

Yes No

Do you have or have you ever had any of the following?

Chronic neckaches/Headaches

Yes No

Tooth Mobility or looseness

Yes No

Grinding/Clenching teeth

Yes No

Bleeding/sore gums

Yes No

Food catching in your teeth

Yes No

Pain or ringing in your ears

Yes No

Jaw muscles tire, stiff, painful

Yes No

Clicking /Popping/Difficulty opening/closing jaw

Yes No

Unpleasant Taste/Bad Breath

Yes No

Indicate which you use and how often

Bristle Brush: Hard, Medium, Soft

Water-Pik

Dental floss

Electric Brush: Type

Have there been any changes in your health in the past two years?

Yes No

If so please list changes

List all prescribed and any over the counter medications

Have you had or do you have any of the following medical conditions

Mitral valve prolapse/Heart Murmur Angina/Chest Pain

Yes No

Pacemaker

Yes No

Heart Surgery/Heart Attack

Yes No

Artificial Heart Valve

Yes No

Congestive Heart Failure

Yes No

Shortness of Breath

Yes No

Rheumatic fever

Yes No

Stroke

Yes No

High Blood Pressure

Yes No

Fainting/Dizziness

Yes No

Kidney Disease

Yes No

Diabetes

Yes No

Auto-Immune Disease

Yes No

HIV Positive (AIDS)

Yes No

Thyroid Disease/Goiter

Yes No

Seizures/Epilepsy

Yes No

Liver disease jaundice, Hepatitis

Yes No

If Yes then Type

Tuberculosis

Yes No

Radiation Treatment for cancer

Yes No

Tumors

Yes No

Arthritis

Yes No

Artificial Joints

Yes No

Chronic Cough

Yes No

Asthma

Yes No

Emphysema

Yes No

Seasonal Allergies

Yes No

Sinus/Nasal Problems

Yes No

MRSA

Yes No

Anemia

Yes No

Bleeding or Clotting Disorder

Yes No

Detached retina/Eye disorder

Yes No

Gastro esophageal reflux disorder(G.E.R.D)

Yes No

Stomach Ulcers

Yes No

Sleep Apnea(use of CPAP machine?)

Yes No

Are you taking or have you ever taken medication for osteoporosis

Yes No

Chemotherapy

Yes No

Have you taken Zometa Aredia

Yes No

Have you taken Psychiatric Treatment

Yes No

Are you allergic to any of the following

Penicillin

Yes No

Codeine

Yes No

Sulfa

Yes No

Latex

Yes No

Iodine

Yes No

Local Anesthetic

Yes No

Sedatives

Yes No

Aspirin

Yes No

Ibuprofen

Yes No

Shellfish

Yes No

Please list other allergies

1

2

3

4

5

6

Chemical Dependency

Smoking

Yes No

How Much? Type Here
How Long? Type Here

Chewing Tobacco

Yes No

How Much? Type Here
How Long? Type Here

History of Alcohol or drug dependency

Yes No

Marijuana

None Medicinal Recreational

Women

Are you taking Birth Control

Yes No

If yes What type

Pills Shots Patch Norplant Other

Are you taking Hormone Replacements(HRT)

Yes No

Are you Pregnant or think you may be?

Yes No

Due Date

Date

Are You Nursing ?

With regards to oral contraceptives it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance.

AUTHORIZATION AND RELEASE

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my family or me during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I understand I am responsible for paying all services rendered at Dental Health PC or Complete Dental Health. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I am aware there are no service fees for 60 days. After that time the interest rate is at 18% annually with a minimum service fee of $5.00 per month for invoices.

Patient Name

First Name Last Name

Signature

Clear

Date

Dental Health PC & Complete Dental Health LLC

CONSENT TO PERFORM DENTISTRY

(Please fill out all of the forms)

I hereby authorize and direct the dentists Kendall S. Wood DDS or Matthew C. Schapper DMD and/or dental auxiliaries of his choice, to perform the following dental treatment or oral surgery procedure(s), including the use of any necessary or advisable local anesthetics, radiographs (x-rays) or diagnostic aids.
- Preventative hygiene treatment (prophylaxis) and the application of topical fluoride.
- Application of "sealants" to the grooves of the teeth.
- Treatment of diseased or injured teeth with dental restorations (fillings and crowns).
- Replacement of missing teeth with dental prostheses. (bridges, partial dentures, full dentures)
- Removal (extraction) of one or more teeth.
- Treatment of diseased or injured oral tissues (hard and/or soft)
- Use of nitrous oxide to control apprehension or disruptive behavior.
- Treatment of malposed (crooked) teeth and/or oral developmental or growth abnormalities.
- Use of local anesthetic to accomplish necessary treatment.
- Adjustment of the contours of teeth to correct malocclusion (poor bite position).
I understand that there are risks involved in dental treatment and hereby acknowledge that these risks will be explained to me, that I will have an opportunity to ask questions regarding the treatment and the risks, and that I fully understand the same.
I agree to the use of local anesthetic and/or the use of nitrous oxide/oxygen analgesia depending on the judgment of the doctor and hygienists. Nitrous oxide/oxygen may occasionally produce nausea and vomiting. I am also aware that the nosepiece may leave an indentation or ring around the nose, which disappears shortly after the procedure. I understand and have been informed of the above risks and complications.
I recognize that during the course of treatment unforeseen circumstances may necessitate additional or different procedures from those discussed. I therefore authorize and request the performance of any additional procedures that are deemed necessary or desirable to oral health and well being in the professional judgment of the dentist.
There are possible risks and complications associated with the administration of local anesthesia, sedation and drugs. The most common of these are swelling, bleeding, pain, nausea, vomiting, bruising, paresthesia, bleeding at or near the injection(s) site, fainting, lip and cheek biting resulting in ulceration and infection of the mucosa. I also understand that there are rare potential risks such as unfavorable reactions to medications in respiratory and cardiovascular collapse (stopping of breathing and heart function) and lack of oxygen to the brain that could result in coma or death. I understand and have been informed of the above risks and complications.
I authorize the doctor to use photographs, radiographs, other diagnostic materials and treatment records for the purposes of teaching, research, scientific publications, and website as well as in office video screen.
I will be advised that the success of the dental treatment to be provided will require that the patient and the parents follow post-operative and post-care instructions of the dentist. I agree that the success of the treatment requires that all postoperative and post-care instructions be followed and that regular office visits as scheduled by my dentist and his auxiliaries must be maintained.
I hereby state that I have read and understand this consent, and that all questions about the procedures will be answered in a satisfactory manner; and I understand that I have the right to be provided answers to questions which may arise during and after the course of my treatment.
I further understand that this consent will remain in effect until such time that I choose in writing to terminate it.
I understand that I have the right to deny such procedures after PARQ (Patient Advised of Risks and Questions were addressed). I knowingly take on all risks to my personal health with no liability to the dentist or any auxiliary when denying recommended dental treatment.

Patient's Name

First Name Last Name

Date

Patient's Signature

Clear

Parent Signature (If patient is a minor)

Clear

Financial Policy Dental Health PC & Complete Dental Health LLC

Kendall S. Wood DDS & Matthew C. Schapper DMD

This statement is to inform you of our financial policy. We are committed to providing you with the highest quality care using only the best material and technology available in the market today. We are also committed to providing you with current information and educational tools so that you may fully participate in maintaining optimum oral health. Our financial policy is intended to facilitate excellent service to you while minimizing our administrative costs.

Your patient portion is due at the time the service is provided. Our office accepts cash, personal checks, Debit cards, MasterCard, Visa, American Express and Discover.

All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and the insurance company. Our office is not a party to that contract. In order for our office to help file your insurance claim, you must give us current insurance information anytime your insurance carrier changes.

As a courtesy to you we will help you process your insurance claim. Insurance payments ordinarily are received within 30-45 days from the time of billing. If your insurance company has not made payment to our office within 60 days, we will ask you to pay the balance due. You will be responsible for seeking reimbursement from your insurance company at that time. Our office does not guarantee that your insurance company will pay for treatment you receive from our practice. We will bill insurance for the treatment that is rendered. However, if your claim is denied, you will be responsible for paying the full amount at that time.

Our office will not enter into a dispute with your insurance company over any claim, although we will provide the necessary documentation that your insurance company may request to sort out any confusion or questions that may arise. It is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company.

We will be happy to provide you with an ESTIMATE of what your patient portion will be for any treatment plan that is recommended. The estimate is not a guarantee of payment from your insurance company. All treatment plan prices will be honored for 30 days.

We reserve the right to charge a $40/appt minimum fee for any dental appointment that is missed or cancelled without a minimum of 24 hours advance notice.

Returned checks and balances older than 60 days are subject to collection fees up to $100 and finance charges at the rate of 1.5% per month or 18% annually with a minimum service fee of $5.00

If you have any questions regarding our financial policy, please ask. We are committed to providing you with the most positive experience in dental care.

Name

First Name Last Name

Date

Signature

Clear

Dental Health PC & Complete Dental Health LLC

Consent for Use and Disclosure of Health Information

I Type Herehave received a copy of the office's Notice of Privacy Practices. This date of date . if you are signing for children please just list their names.

Children(s)

1

2

3

4

5

6

Please fill out this section if someone other than yourself can acquire information or pay on your account:

I Type Here authorize Dental Health P.C. and Complete Dental Health L.L.C
to provide information to or receive information from:

Name

First Name Last Name

Relation

Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code

Phone Number

Please enter a valid phone number.

I understand that by signing this form I will consent to use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.

Before I sign, I have the right to read and/or request the Notice of Privacy Practices. This notice provides a description of our: treatment, payment activities, health care operations, the uses and disclosures we may make of your protected health information, and other important matters about your protected health information.

I understand that I have the right to revoke this authorization at any time. I understand that in order to revoke this authorization, I must do so in writing and present my written revocation to the contact person mentioned below. I understand that the revocation will not apply to information that has already been disclosed in response to and in reliance on this authorization.

Contact Person:

Dental Health P.C.
869 NW 23rd St
Corvallis OR 97330
Ph: 541-757-1829
Fax: 541-757-8628

Complete Dental Health L.L.C.
1123 Hill St SE Suite A
Albany OR 97322
Ph: 541-928-6622
Fax: 541-928-6958

Signature

Clear

Email

example@example.com

Date

You are entitled to a copy of this consent after you sign it.

We have attempted to obtain written acknowledgement of receipt of our Privacy Practices but acknowledgement could not be obtained due to:

Communication Barrier Individual Refused to sign Emergency Situation Other