Specialized Periodontal New Patient Paperwork

SPECIALIZED PERIODONTAL
IMPLANT TEAM
Alfred L. Lopez, DDS 10409 Montgomery Parkway NE, Suite 100 Albuquerque, NM 87111 (505)717-2928 alopez@specializedperiodontal.com

Our office sends appointment reminders by text & email
Date

MonthDayYear
Date
Name
Preferred
Date Of Birth

MonthDayYear
Date
SSN
Marital Status
Address
City
State
Zip
Home Phone
Cell Phone
Work Phone
Email
Employer
Occupation
Referred By
General Dentist
Dental Insurance Information
Insurance Company
Subscriber Name
Subscriber SSN Or ID#
Subscriber Employer
Subscriber Date Of Birth
Group #
SECONDARY DENTAL INSURANCE INFORMATION
Insurance Company
Subscriber Name
Subscriber SSN or ID#
Subscriber Employer
Subscriber Date of Birth

MonthDayYear
Date
Group #
ACKNOWLEDGMENT OF FINANCIAL RESPONSIBILITY

1. We are providing a professional service at a reasonable fee. Payment is expected at the time of service. Payment may be made in the following ways: Visa/ MasterCard/Discover Check Cash
2. Insurance estimates are provided as a courtesy. In the event that your insurance carrier pays less than the estimated amount, you are responsible for the unpaid balance. 3. We do not invoice patients. All balances must be paid at the time of service. This also allows us to keep our fees as low as possible. 4. Monthly Payment Program: We have contracted with Care Credit to provide a monthly payment program to our patients. This service allows you to make small monthly payments and has an interest free option. 5. Discounts: Our policy is not to discount for any reason. This allows our practice to keep our fees for everyone as low as possible. 6. Missed appointments: Appointments are considered confirmed at the time it is scheduled. I understand the office will try to contact me at the numbers I have provided in advance to confirm my appointment as a courtesy. I understand that the office reserves the right to charge for each broken appointment if adequate notice is not given. I understand that leaving a message after hours for the following day is not considered adequate notice since the office will not receive the message until the next working day.

I understand and agree to the above information
Signature

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Date

MonthDayYear
Date
ACKNOWLEDGEMENT OF PRIVACY RIGHTS

My signature confirms that I have been informed of my rights to privacy regarding my protected health information, under the Health Insurance & Accountability Act of 1996 (HIPAA I understand that this information can and will be used to: 1. Provide and coordinate my treatment among a number of health care providers who may be involved in the treatment directly or indirectly. 2. Obtain payment from third-party payers for my health care services. 3. 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 practices. I understand that my dental provider has the right to change the Notice of Privacy Practices, and that I may request to obtain a current copy.

I understand that I may request in writing that this office restrict how my private information is used or disclosed to carry out treatment, payment or health care operation. I understand that the office is not required to agree to my requested restrictions, but if the office does agree then it is bound to abide by such restrictions.
Signature

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Date

MonthDayYear
Date
Relationship to patient (if signed by a representative of patient)
MEDICAL HISTORY
Although dental personnel primarily treat the area in your mouth, your mouth is part of your entire body. Health problems that you may have, or medication you may be taking could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Please Provide your height and weight
Height
Weight
When Did You Last Have A Medical Checkup
Are You Under A Physician's Care Now?

YesNo
Please Explain
Have You Been Hospitalized Or Had A Major Operation?

YesNo
Please Explain
Have You Ever Had A Serious Head Or Neck Injury?

YesNo
Please Explain
Do You Consider Your Medical Health To Be Good?

YesNo
Are You On A Special Diet?

YesNo
Do You Use Tobacco?

YesNo
Do You Drink Alcohol Regularly?

YesNo
Do You Use Controlled Substances?

YesNo
Do You PRE-MED For Any Reason?

YesNo
Any Family History Of The Following?:

Heart DiseaseCancerDiabetesGum Disease
Are You?:

Pregnant/Trying To Get PregnantNursingTaking Oral Contraceptives
Are You Allergic To The Following?:

AspirinPenicillinCodeineAcrylicMetalLatexLocal AnestheticSulfaOther
Do You Have, Or Have You Had, Any Of The Following?:

AlcoholismDental NervousnessHepatitis A, B or CRenal DialysisAIDS/HIV PositiveDepressionHerpesRheumatic FeverAlzheimer's DiseaseDiabetesHigh Blood PressureRheumatismAnaphylaxisDrug AddictionHives or RashScarlet FeverEasily WindedAnemiaShinglesHPVAngina / Chest PainEmphysema/COPDHypoglycemiaSickle Cell DiseaseEpilepsyIrregular HeartbeatSinus TroubleSulfaArtificial Heart ValveExcessive BleedingKidney ProblemsSleep Apnea / CPAPArtificial Joint / Pre-MedFainting Spells / DizzinessLeukemiaStomach/Intestinal DiseaseFrequent CoughLiver DiseaseStrokeAsthmaFrequent HeadachesLow Blood PressureSwelling of LimbsBlood DiseaseBlood TransfusionYellow JaundiceLung DiseaseThyroid DiseaseBreathing ProblemsGlaucomaMitral Valve ProlapseTuberculosis/PPD PositiveBruise / Bleed EasilyHay FeverOsteoporosis/OsteopeniaTumors or GrowthsCancerPain in Jaw JointsHeart Attack / FailureUlcersChest PainsHeart Murmur / Pre-MedPersistent CoughUnexplained Weight LossHeart PacemakerProsthetic JointCold Sores / Fever BlistersCongenital Heart DisorderHeart Trouble / DiseasePsychiatric CareConvulsions/SeizuresHemophiliaRadiation Treatments
Have You Ever Had A Serious Illness Not Listed Above?

YesNo
Please Explain
DENTAL HISTORY
The following information is required to help with your dental diagnosis. Thank you for answering the following questions.
General Dentist
Referring Doctor
Have You Been Experiencing Pain From Your Mouth Lately?

YesNo
Are You Experiencing Pain From Your Mouth At This Time?

YesNo
Have You Had Swollen Areas Of Gum Lately?

YesNo
When did you last have your teeth cleaned?
How often have you had your teeth cleaned in the last 5 years?
Do Your Gums Bleed?

YesNo
Do You Have Dry Mouth?

YesNo
Do Your Gums Bleed When You Brush?

YesNo
Are Your Teeth Sensitive To Hot, Cold or Sweets?

YesNo
Which teeth?
How often do you brush your teeth?
What Type Of Toothbrush Do You Use?

ElectricManual
How often do you floss your teeth?
Do You Smoke?

YesNo
How Much?
What Do You Smoke?
Have You Ever Had Periodontal (Gum) Treatment(s)?

YesNo
When
Doctor's name
Treatment performed
GENERAL QUESTIONS
Do You Wish To Talk Privately About Any Problem?

YesNo
Do You Currently Take Any Medications?

YesNo
Please List All Medications And Why You Are Taking Them:
To the best of my knowledge, the questions on these forms have been accurately answered. I understand that providing incorrect medical history information can be dangerous to the patient's health. It is my responsibility to inform the dental office of any changes in the patient's medial status.
Print Name
Date

MonthDayYear
Date
Signature,

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SPECIALIZED PERIODONTAL

IMPLANT TEAM

Dental Insurance Information

SECONDARY DENTAL INSURANCE INFORMATION

MEDICAL HISTORY

DENTAL HISTORY

GENERAL QUESTIONS