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Patient Information
Patient Name
*
Date of Birth
*
SS#
*
Patient Address
*
City
*
State
*
Zip
*
Employer
*
Home Phone
Cell Phone
Work Phone
Email
*
Who may we thank for referring you?
Dental visits are confirmed by PHONE, TEXT MESSAGE, or EMAIL.
Please let us know if you prefer to not receive appointment messages by text or email.
Email
Yes
Text
Yes
Who is your Medical Doctor/ Pediatrician/ Family Doctor?
M.D.’s Phone
Pharmacy Name
* Required
INSURANCE INFORMATION
Insured’s Employer
Insured’s Insurance Carrier
Policy Holder
Policy Holder’s Date of Birth
Effective Date
Insurance ID# or SS#
Secondary Insurance Employer
Insured’s Insurance Carrier
Policy Holder
Policy Holder’s Date of Birth
Effective Date
Insurance ID# or SS#
ASSIGNMENT AND RELEASE OF BENEFITS
I certify this information is true and correct to the best of my knowledge. Des Moines River Dental Care has my authorization to adhere to my consents outlined on this form. I understand that I am financially responsible for all charges whether or not paid by said insurance. I hereby authorize said assignee to release medical information to secure payment.
I understand and agree with what I read
*
Yes
Your Name
*
Date of Acceptance:
*
Des Moines River Dental Care complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, age, disability, or sex.
* Required
Who do you want to share information with?
Please keep in mind that this includes anyone on your behalf sharing the responsibility of:
Cancelling or scheduling and appointment, inquiring about treatment, paying a bill on my account.
*This is required, if you wish to share with no one, please indicate by typing none on each line.
Spouse
*
Parent
*
Other
*
I give permission to Des Moines River Dental Care to share my dental history, recommended treatment, and balance info with anyone that I have listed in the Spouse, Parent, or Other fields.
I Agree with what I read
*
Yes
Your Name
*
Today’s Date
*
* Required
Reason for visit
What Brought you here today?
*
How long since your last dental visit?
*
* Required
Dental Complications
Have you had any dental complications in the past?
*
Yes
No
If yes, explain here.
* Required
Orthodontics
Have you had orthodontics?
*
Yes
No
If yes, explain here.
* Required
Gum disease
Have you ever been treated for gum disease?
*
Yes
No
If yes, explain here.
* Required
Appearance of your teeth or smile
Is there anything you would change about the appearance of your teeth or smile?
*
Yes
No
If yes, explain here.
* Required
Bisphosphonates?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
*
Yes
No
If yes, explain here.
* Required
Pre-Medication
Has a physician recommended you take a Pre-Medication (antibiotics) for dental treatment?
*
Yes
No
If yes, explain here.
* Required
Reactions
Have you ever had a reaction after receiving dental anesthetic?
*
Yes
No
If yes, explain here.
* Required
Hospitalized
Have you been hospitalized within the past year?
*
Yes
No
If yes, explain here.
* Required
Women: Are you…
Pregnant
Yes
No
If yes, Number of weeks?
Nursing
Yes
No
Taking oral contraceptive
Yes
No
Tobacco
Do you use tobacco (including smokeless)
*
Yes
No
* Required
Controlled substances
Do you or have you used controlled substances?
*
Yes
No
* Required
Are you allergic to any of the following?
Aspirin
Penicillin
Codeine
Acrylic
Metal
Latex
Sulfa Drugs
Local Anesthetics
Do you have, or have you had, any of the following? (Select the checkboxes for what you have had)
AIDS/HIV Positive
Excessive Thirst
Mitral Valve Prolapse
Alzheimer's Disease
Fainting Spells/Dizziness
Osteoporosis
Anaphylaxis
Frequent Cough
Pain in Jaw Joints
Anemia
Frequent Headaches
Parathyroid Disease
Angina
Genital Herpes
Psychiatric Care
Arthritis/Gout
Glaucoma
Radiation Treatments
Artificial Hearth Valve
Hay Fever
Recent Weight Loss
Artificial Joint
Hearing Impairment
Renal Dialysis
Asthma
Heart Attack/Failure
Rheumatic Fever
Blood Disease
Heart Murmur
Rheumatism
Blood Transfusion
Heart Pacemaker
Scarlet Fever
Breathing Problems
Heart Trouble/Disease
Shingles
Bruise Easily
Hemophilia
Sickle Cell Disease
Cancer
Hepatitis A
Sinus Trouble
Chemotherapy
Hepatitis B or C
Spina Bifida
Chest Pains
Herpes
Stomach/Intestinal Disease
Cold Sores/Fever Blisters
High Blood Pressure
Stroke
Congenital Heart Disorder
High Cholesterol
Swelling of Limbs
Convulsions
Hives or Rash
Thyroid Disease
Cortisone Medicine
Hypoglycemia
Tonsillitis
Diabetes
Irregular Heartbeat
Tuberculosis
Drug Addiction
Kidney Problems
Tumors or Growths
Easily Winded
Leukemia
Ulcers
Emphysema
Liver Disease
Venereal Disease
Epilepsy or Seizures
Low Blood Pressure
Yellow Jaundice
Excessive Bleeding
Lung Disease
Des Moines River Dental Care PLLC NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
I understand that under the Health Insurance Portability & Accountability act of 1996(“HIPPA”), I have certain rights to privacy regarding my protected health information(PHI). 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 may be involved in the treatment, directly and indirectly
Obtain payment from third-party payers
Conduct normal healthcare operations such as quality assessments and physician certifications
I received, read, and understood your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my PHI. 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 to obtain a current copy of this Notice of Privacy Practices.
I understood everything I read.
*
Yes
Patient Name or Legal Guardian
*
Date:
*
* Required