Patient Portfolio Version 2 2022

Patient Care Portfolio

Please make sure you have a scheduled appointment prior to filling out this form.
We are glad you're here…

We are always accepting new patients and would love to be the ones to provide you with excellent dental care here in Indianapolis, Indiana! If you have records that you believe are current, it is always helpful to bring them with you or have them sent to our office prior to your appointment. Current dental records include having a Panorex or a Full Mouth Set of radiographs within the last 5 years or having a set of Bitewings within the last year. Your previous office may require you to sign a "release of records" to allow them to send your records/x-rays to us. They can either give them to you or email them to our office at isaacsfamilydental@gmail.com.

Please take the time to complete these forms.
If you need to exit the form prior to finishing, scoll to the bottom and click "SAVE". You will receive an email with access to return to this form later.
Name*

First NameMiddle NameLast Name
Preferred Name
Date of Birth

MonthDayYear
Date
Social Security # *
Sex*

MaleFemale
Marital Status

SingleMarried
Primary Phone Number*
Secondary Phone Number
Email*
example@example.com
Street Address*

Street Address

Street Address Line 2

City

Zip Code
City/State*

Street Address

Street Address Line 2

CityState

Zip Code
Zip Code
Employer
Occupation
Emergency Contact
Name

First NameLast Name
Relationship
Phone Number
Please enter a valid phone number.
How did you find us? Let us know…
2022 Office Policies

Isaacs Family Dental
I hereby guarantee payment in full of any and all fees in consideration for dental services I am responsible for. I understand that I am responsible for all fees not covered by my dental insurance including deductibles and co-payments. I understand payment is due in full for those fees at the time service is performed.

As a courtesy, we contact your dental insurance provider to check your benefits and submit claims on your behalf. We are not responsible for and can make no guarantees as to the coverage your dental insurance will provide. As the patient, it is ultimately your responsibility to know your dental insurance and benefits and you are responsible for any balance that is not paid by dental insurance. We require that all patients, with or without insurance, pay for their treatment at the time of service. We will be happy to file a pre-determination prior to any treatment to your insurance so we can get more of an accurate estimate of what they should pay, but it is still not a guarantee of their payment.

*We accept any major credit card such as American Express and Discover, cash, check. If your advised treatment creates a financial problem on your part, companies like Care Credit (6 months no interest) and Lending Club (12 months no interest) are able to give you affordable payments. We do not have in-office payment plans besides through these companies.

*In an effort to control the cost of our dental fees, we do require a 24 HOUR NOTICE to change or cancel a scheduled appointment. This charge of $30 per hour for hygiene and $50 per hour you were scheduled with the doctor that will automatically be applied to your account. We give out appointment cards, send out texts and e-mails, and call to confirm. You must speak to a staff member to cancel any appointment. We do not accept cancellations via text or e-mail.

*We pride ourselves for being on time for your appointment and we ask that you do the same for us. Arriving 15 or more minutes late could result in having to reschedule. More than 3 failed appointments could result in dismissal.

*The office will charge $30 for a returned check. In the event of a returned check, we reserve the right to have you pay in cash for future visits.

*If the account is turned over for advanced collection services, the patient or responsible party will be expected to pay all collection fees (under $175, there is a $50 collection fee and $175 and over, there is a 30% collection fee), court costs, and reasonable attorney fees.

*Due to OSHA, HIPAA, and government regulations; patients and staff members are the only ones permitted in treatment rooms. You may escort someone back to get them situated but you will asked to wait in the lobby. Any consults/questions can be talked about after the treatment in our consult room.

*In order for you to be seen in our office, you must sign our office policies at the end of this form. You may ask for a copy of this form.
Primary Dental Insurance Information

E-mail a photo/scan of your insurance card (front & back) to isaacsfamilydental@gmail.com
Do you have dental insurance? If yes please complete the information below.*

YesNo
Subscriber Name

First NameLast Name
Relationship to Patient

SelfSpouseChildOther
Subscriber Employer
Insurance Company Name
Subscriber SSN and/or MEMBER ID#
Group #
Insurance Phone #
Please enter a valid phone number.
Subscriber Date of Birth

MonthDayYear
Date
Insurance Provider Address

Street Address

Street Address Line 2

City

Zip Code
City/State

Street Address

Street Address Line 2

CityState

Zip Code
Zip Code
I give permission to submit claims on my behalf and share information with my Primary insurance if needed

YesNo
Secondary Dental Insurance Information

Please leave blank if none. E-mail a photo/scan of your insurance card (front & back) to isaacsfamilydental@gmail.com
Subscriber Name

First NameLast Name
Relationship to Patient

SelfSpouseChildOther
Subscriber Employer
Insurance Co. Name
Subscriber SSN and/or MEMBER ID#
Group #
Insurance Provider Address

Street Address

Street Address Line 2

City

Zip Code
City/State

Street Address

Street Address Line 2

CityState

Zip Code
Zip Code
Insurance Phone #
Please enter a valid phone number.
Subscriber Date of Birth

MonthDayYear
Date
I give permission to submit claims on my behalf and share information with my Secondary insurance if needed

YesNo
Medical History
Are you currently under the care of a physician? If so, please list their name, phone number, and what they are treating you for.

Physician First NamePhysician Last Name
Physician Phone #
Please enter a valid phone number.
Treatment
Pharmacy Name
Pharmacy Phone #
Please enter a valid phone number.
Do you use any form of tobacco?

YesNo
If yes, please list type and frequency
Do you have any of these conditions?

Abnormal BleedingAlcohol AbuseAllergiesAnemiaAngina PectorisArthritisArtificial Heart ValveAsthmaBlood TransfusionCancerChemotherapyCongenital Heart DefectDiabetes
Difficulty BreathingDrug AbuseEmphysemaEpilepsyFacial SurgeryFainting SpellsFever BlistersFrequent HeadachesGlaucomaHIV + AIDSHeart AttackHeart MurmurHeart SurgeryHemophiliaHepatitis AHepatitis BHepatitis CHigh Blood PressureJoint ReplacementKidney ProblemsLiver DiseaseLow Blood PressureMitral Valve ProlapsePace MakerPsychiatric CareRadiation TherapyRheumatic FeverSeizuresShinglesSickle Cell DiseaseSinus ProblemsSleep ApneaStrokeThyroid ProblemsTuberculosisUlcersDementiaSexually Transmitted DiseaseOther
Do you have a latex allergy?

YesNo
Do you require PRE-MED (Antibiotic) before your dental appointment?

YesNo
Do you have any artificial joints?

YesNo
Artificial joint type
Please list PRE-MED medication if any
Are you currently taking any prescribed medications?

YesNo
Please List current medications here:
Are you currently nursing?

YesNoN/A (Male)
Are you currently pregnant?

YesNoN/A (Male)
If you are pregnant, how many weeks?
Example: 12 Weeks. N/A (Male)
Do you have any disease, condition or problem that you feel we should know about? If so, please describe
Sleep Assessment
Name*

First NameLast Name
Date*

MonthDayYear
Date
Sleep-Related Disordered Breathing (SRDB) is a common problem that can have serious health consequences and unfortunately it often goes undiagnosed and untreated. Since 1 in every 5 Americans experience this, the American Dental Association (ADA) has recommended that dentists check all patients for signs and symptoms that put them at risk for this problem. Completion of this form and your exam today enable Isaacs Family Dental to provide education, determine your risks, and refer you to the appropriate health care provider for assessment and treatment if needed.
Have you ever been diagnosed with a sleep problem??

YesNo
Have you ever been treated for a sleep problem?

YesNo
Are you currently being treated for a sleep problem?

YesNo
If yes, how is your sleep problem being treated? (Check all that apply)?

CPAP or BPAP MachineOral Appliance/DeviceSurgeryOther
If you have been given a CPAP or BPAP machine, do you use it every night?

YesNo
Are you comfortable with your CPAP/BPAP and satisfied with its use?

YesNo
If you have been given an Oral Device/Appliance to help with sleep problems are you comfortable with it and satisfied with its use?

YesNo
Part 1: Epworth Sleepiness Scale

Select the number of your response below. Use this scale:

0 = Never 1=Slight 2=Moderate 3= High

How likely are you to doze off while doing the following activities?
Being a passenger in a motor vehicle for an hour or more

0123
Sitting and talking to someone

0123
Sitting and reading

0123
Watching TV

0123
Sitting inactive in a public place

0123
Lying down to rest in the afternoon

0123
Sitting quietly after lunch without alcohol

0123
In a car, while stopped for a few minutes in traffic

0123
Add each number from the previous questions, enter total here:
Part 2:

Enter "Yes" or "No" in the space provided:
Have you ever been told you snore?

YesNo
Do you wake up choking or gasping?

YesNo
Do you have High Blood Pressure?

YesNo
Do you have Diabetes?

YesNo
Have you ever experienced an irregular heart rhythm?

YesNo
Part 3: Snoring

Select "Yes" or "No" to the following questions:
Does snoring cause any problems at home?

YesNo
Would you like to fix your snoring problem?

YesNo
Part 4: Epworth Sleepiness Scale
(To be completed by Assistants or Hygienist):

(female > 15 or Male > 16.5) Height
BMI
(BMI> 30)
(BMI> 30)

Total Score
(Class III or IV) Scalloped Tongue?
Schedule TMV
Dental History

Please e-mail any recent x-rays to isaacsfamilydental@gmail.com before your appointment. NOTE: If recent X-rays are not available, Isaacs Family Dental will take new images and a fee could occur.
Rate your current dental health:

GoodFairPoor
How many times do you floss per week?

1 - 45 - 1011 or More
When was your last dental visit?

MonthDayYear
Approximate date is OK.
When was your last dental cleaning?

MonthDayYear
Approximate date is OK.
How can we better accommodate you during your visit?
Are there any services/concerns you would like to inquire about?
Tell Us How You Are Feeling…

I am currently in pain (jaw, face, cheeks, joints, throat or temples).I am clenching or grinding my teeth.It hurts when I chew or open wide to take a bite.I have jaw symptoms or headaches upon waking up in the morning?I don't like my smile.There are some things I would change about my smileI'm not happy with the color of my teeth.I've had gum disease.My gums bleed.I've had a deep cleaning or scaling and root planing.My teeth are sensitive to heat, cold and other issues.I take fluoride supplements.I've had serious/difficult problem with previous dental work.I've had unfavorable dental experiencesI'm apprehensive about dental treatmentI do gag easily.I snore.
2022 Isaacs Family Dental Office Policies

I hereby guarantee payment in full of any and all fees in consideration for dental services I am responsible for. I understand that I am responsible for all fees not covered by my dental insurance including deductibles and co-payments. I understand payment is due in full for those fees at the time service is performed.

As a courtesy, we contact your dental insurance provider to check your benefits and submit claims on your behalf. We are not responsible for and can make no guarantees as to the coverage your dental insurance will provide. As the patient, it is ultimately your responsibility to know your dental insurance and benefits and you are responsible for any balance that is not paid by dental insurance. We require that all patients, with or without insurance, pay for their treatment at the time of service. We will be happy to file a pre-determination prior to any treatment to your insurance so we can get more of an accurate estimate of what they should pay, but it is still not a guarantee of their payment.

* We accept any major credit card such as American Express and Discover, cash, check. If your advised treatment creates a financial problem on your part, companies like Care Credit (6 months no interest) and Lending Club (12 months no interest) are able to give you affordable payments. We do not have in-office payment plans besides through these companies.

* In an effort to control the cost of our dental fees, we do require a 24 HOUR NOTICE to change or cancel a scheduled appointment. This charge of $30 per hour for hygiene and $50 per hour you were scheduled with the doctor that will automatically be applied to your account. We give out appointment cards, send out texts and e-mails, and call to confirm. You must speak to a staff member to cancel any appointment. We do not accept cancellations via text or e-mail.

* We pride ourselves for being on time for your appointment and we ask that you do the same for us. Arriving 15 or more minutes late could result in having to reschedule. More than 3 failed appointments could result in dismissal.

* The office will charge $30 for a returned check. In the event of a returned check, we reserve the right to have you pay in cash for future visits.

* If the account is turned over for advanced collection services, the patient or responsible party will be expected to pay all collection fees (under $175, there is a $50 collection fee and $175 and over, there is a 30% collection fee), court costs, and reasonable attorney fees.

* Due to OSHA, HIPAA, and government regulations; patients and staff members are the only ones permitted in treatment rooms. You may escort someone back to get them situated but you will asked to wait in the lobby. Any consults/questions can be talked about after the treatment in our consult room.

* In order for you to be seen in our office, you must sign our office policies at the end of this form. You may ask for a copy of this form
Notice of Privacy Practices & HIPAA

We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign in the signature box (below) to acknowledge receipt of the Notice.

We cannot discuss your Protected Health Information (PHI) or account information with anyone other than yourself unless you authorize us to do so. Please list below the names(s) of any individual(s) that you authorize our office staff to discuss your care. Your PHI may be shared with the individual(s) listed below unless you notify us otherwise in writing.

I hereby give permissions for Dr. David Isaacs’ Dental office to disclose information to:

♦ Healthcare provider taking part in your medical/dental care
(Example: If we have to go over medications, your health, etc., with any other medical professional)

♦ Your insurance company, if any
(Example: Giving us permission to submit claims to your insurance company)
(Refusal to check, you will submit your claim to your denal insurance with information we provide to you)

For Example, If a spouse calls asking a question regarding a bill on your behalf, we cannot share information unless their name is listed. A Notice of Dr. David Isaacs’ Notice of Privacy Practices will be provided upon request.

♦ I understand I can request & obtain a copy of Dr. David Isaacs’ Notice of Privacy Practices

♦ I hereby give permissions for Dr. David Isaacs’ Dental office to disclose information regarding any appointment or treatment to: (Please List Approved Contact Name(s) Here (If no one, please leave blank.)

Approved Contacts:
Spouse:

First NameLast Name
Guardian:

First NameLast Name
Other Relative:

First NameLast Name
Other:

First NameLast Name
Acknowledgement of Receipt of Notice of Office Policies, Privacy Practices, Annual HIPAA, and Office Policies Form

I hereby recognize receipt of the office policies, understand my responsibilities as a patient/responsible party/payor, acknowledge notice of privacy & HIPAA policies, and give permission for Isaacs Family Dental to disclose information regarding any appointment, treatment, balance, or account info to approved contacts (listed above). I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment, with my informed consent.
Signature

Clear
Date

MonthDayYear
Date
Should be Empty:

Patient Care Portfolio

Emergency Contact

2022 Office Policies

Primary Dental Insurance Information

Secondary Dental Insurance Information

Medical History

Dental History