patient information · patient survey medical history would you like to hear about homeopathic...

3116 Mount Vernon Ave

Alexandria, VA 22305

703- 745-5496 | www.dentalexcellenceva.com

Check here if self

Responsible Party Information (Person Responsible for Account)

Name: Preferred Name: Date of Birth: Sex M F

Address: City:

State: Zip: Social Security #:

Primary Phone: Secondary Phone:

Work Phone: Email: Marital Status:

Employer: Occupation:

How did you hear about our practice? Emergency Contact:

Relation to patient: Phone:

Name: Birthdate: Relationship to Patient:

Address (If different from above): City: State: Zip:

Social Security #: Phone#:

NO INSURANCE

How did you hear about our office? ______________________________________________ We want to share with you what our beliefs are about our practice our philosophies to help each patient achieve the highest level of dental health appropriate for them. Recognizing not all patients have the same dental needs or desires. With that in mind, we would ask you to identify how you would like to be seen in our practice by checking which of these three levels seems appropriate for you. Please understand, is not uncommon for patients to choose a different path, after they've experienced our office. There are three basic levels of care that are provided, please choose one:

Reactive Care Model: You want to take care of Urgent and emergency needs such as disease, dental decay and infections. Proactive Care Model: You want to be seen for exam and hygiene visit twice a year and take care of issues as they come

up such as single tooth dentistry.

Regenerative Care Model: Highest Level of Care, you want complete detailed exam, a report of all findings, develop a

long term plan, and typically chooses restorative solutions that are based on PROPER FUNCTION, PROPER ALIGNMENT,

longevity and appearance, not just on solving an immediate problem.

We want to match you expectation and improve your experience. We hope these three levels make sense to you. As we stated

before, it's not uncommon for patients to change levels of care after beginning treatment with us.

Patient Information

Insurance Information

MEDICAL INSURANCE - PRIMARY

Subscriber Name:__________________________ Relationship to patient:__________________ Subscriber DOB (M/D/Y):___________________

Subscriber SSN/ID: ___________________________ Subscriber Employer:____________________ Group Number:______ ______________________________________

Insurance Company Name:____________________________ Insurance Company Phone #:__________________________________

INSURANCE- PRIMARY Subscriber Name: _____________________________________________________ Relationship to Patient: ___________ Subscriber DOB (M/D/Y): ________________________________________ Subscriber SSN/ID: _____________________________________________________ Subscriber Employer: __________________ Group Number: __________________________________________________________________________ Insurance Company Name: Insurance Company Phone #:

INSURANCE- SECONDARY NO SECONDARY

Subscriber Name:_______________________________

Relationship to Patient:___________________________

Subscriber DOB (M/D/Y):___________________________

Subscriber SSN/ID:___________________________

Subscriber Employer:_________________________ Group Number:______________________________ Insurance Company Name: ______________________ Insurance Company Phone #: _________________________

http://www.dental-alexandria.com/




What dental problems cause you the most trouble?

Is there anything you would like to discuss or change about your smile or teeth?

Are you interested in professional teeth whitening? Yes No

Why did you leave your previous dentist?

Are you particularly sensitive to anything at the dentist? Yes No Explain:

How would you describe the perfect dentist? Be specific.

What key factors most influence you when choosing a Dentist?

Would you like to hear about injection free dental treatment? Yes No

Are you interested in any conscious sedation therapy? Yes No

Are you currently seeing alternative care practitioners or non-traditional therapy/medical treatment such as

chiropractor, acupuncture, and homeopath? Yes No Explain:

What would be the most convenient days for you to visit us?

Most convenient hours? (Circle one) Morning or Afternoon

Are you interested in Alternative/Holistic and preventive options for your oral health and over health? Yes No

How can we accommodate you better during your dental visit?

Name and phone of your physician:

Name of Preferred Pharmacy & Phone#:

Are you currently taking any drugs or medications? Yes No Please list:

Women: Are you pregnant? Yes No Nursing? Yes No Are you taking birth control pills? Yes No

Have you taken or currently taking medications for osteoporosis known as bisphosphonates (Example: Fosamax, Actonel, or Boniva)

Yes No If yes please specify:

Do you take or have taken Phen-Fen or Redux? Yes No

Do you smoke or chew tobacco? Yes No If Yes For how long? How Much?

In the last year have you seen a:

Do you snore? Yes No

Use a CPAP?

Yes No

Had a sleep study? Yes No

If Yes Please Specify:

Insomnia? Yes No Less than 7 hours sleep/night? Yes No

How many times do you wake up at night?

Are you allergic to: Penicillin Codeine Latex Iodine Tetracycline Barbiturates Sulfa Metal

Acrylic Aspirin Dental Anesthetics Erythromycin Other NONE

Are you currently in pain? Yes No If Yes Please Explain:

Patient Survey

Medical History

Would you like to hear about homeopathic relaxation for any dental treatment? Yes No

Do you suffer from anxiety or fear of receiving dental treatment? Yes No Explain:

Medical History-Continued





Please Check if you have or have a history of the following:

AIDS/HIV

ADD/ADHD

Alzheimer’s Disease

Anaphylaxis Anemia

Angina

Alcohol Addiction

Drug Addiction

Arthritis

Rheumatism

Artificial Heart Valves

Artificial Joints Asthma

Bleeding Disorder

Blood Disease Blood

Transfusion Cancer

Chemotherapy

Chest Pain

Cold Sore/Fever Blister

Circulatory Problems

Congenital Heart Disorder

Convulsions

Cortisone Treatments

Cough – persistent

Depression

Diabetes – Type

Digestive Issues

Daytime Fatigue/Sleepiness

Difficulty Breathing

Hay Fever

Heart Attack/Failure

Heart Murmur Heart

Problems Hemophilia

Hepatitis – Type

Herpes

High Blood Pressure

Hives or Rash

Hypoglycemia

Irregular heartbeat

Kidney Disease

Leukemia

Liver Disease

Low Blood Pressure

Mitral Valve Prolapse

Mouth Breathing

Neurological Issues

Nasal Congestion

Nervous Problems

Osteoporosis

Pacemaker Parathyroid

Disease Psychiatric

Care Radiation

Treatment Rheumatic

Fever Scarlet Fever

Shingles

Sickle Cell Disease

Sinus Trouble

Spina Bifida

Steroid Therapy

STD

Stomach/Intestinal Disease

Stroke

Swollen Feet or Ankles Swollen

Neck Glands Thyroid Disease

Easily Winded

Emphysema/Lung Disease

Excessive Bleeding Excessive

Thirst

Epilepsy Seizures

Fainting Spells

Dizziness

Frequent Cough

Frequent Diarrhea

Glaucoma

Gout Tonsillitis

Tuberculosis

Tumor/Growth

Ulcer

Yellow Jaundice

Pain/Ringing Around Ear

Please Answer the following: Please Check if you have or have a history of the following:

-Do you require antibiotics before dental treatment? Yes No

-Have you seen an Orthodontist, had your bite adjusted,

or been treated for TMJ? Yes No

-Are your teeth sensitive to:

Heat Cold Sweets Biting Pressure

-Have you been instructed regarding proper home care? Yes No

-How often do you brush your teeth?

-How often do you floss?

Clenching

Grinding

Facial pain

Bell's Palsy

Facial Surgery

Headaches, earaches and/or neck pain

Mouth

Ulcers or Cold Sores

Broken Teeth or Broken Fillings

Bleeding, swollen or irritated gums

Loose, tipped or shifting teeth

Bad breath or bad taste in mouth

Muscle pain in jaw, temple, neck area

Burning sensation on tongue

Food collection between teeth Dry mouth

Lip, cheek or tongue biting

Gum Recession

Speech issues

Jaw Joint Discomfort

Dental History





Welcome and thank you for letting us serve you. We look forward to working with you. In order to prevent any misunderstandings we ask that all patients read and sign our Policy page. If you have any questions please ask us!

Insurance: In order to be focused on patient care here at the office all insurance billing and accounting functions are done by an external Dental billing company. They help submit your claim as a courtesy to you. It may take anywhere between 30-90 days for your insurance to pay for services you received from us on your behalf. We make every effort to appeal your case in event that maybe needed. However, you are responsible for your account. Insurance companies do not guarantee payment based on the information they provide to us. You are ultimately responsible for knowing your benefits. As a courtesy we provide an estimate for treatment needed. This includes estimated co-pays and deductibles. This is only an estimate. Any amount that is not covered by your insurance is your financial responsibility. We 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 and/or your employer and the insurance company.

Scheduling Policy: We value your time and make every effort to provide treatment in a timely manner and In as few visits as possible. We ask that you value our time as well by arriving on time. We require two business

days’ notice for cancellation or re-scheduling appointments. If you cancel, reschedule or fail to show for an appointment within two business days, you will be charged a fee of $150 per hour. When we make your appointment, we are reserving a room and doctor’s time for your particular needs. We ask that if you must change an appointment, please give us at least 48 business hours’ notice. This courtesy makes it possible to give your reserved room to another patient who needs to be seen.

Payments: Payment is due at the time of service. For any treatment, you will be expected to apply a reservation fee of 25% at the time of scheduling. In addition to Cash, Checks, Visa, Master Card, Discover, and American Express we offer other payment options-please see our financial coordinator for details. If payment is made with a check, and it is returned, you will be responsible for a $35.00 returned check charge. If your account becomes delinquent (over 90 days), it will be turned over to a local collection agency and you will incur any collection costs and any related attorney’s fees.

Information Use: Dental Excellence Integrative Center transmits records and personal information via mail and electronically, using email, fax, phone and other means. By signing, you authorize Dental Excellence Integrative Center to share your records with other dental and medical providers, offices and you. We take photographs, and/or videos of face, jaws and teeth, before, during and after treatment. By signing, you consent to the photographs to be used for dental records, dental research, and dental education including lectures, demonstrations and professional publications. There is no compensation, financial or otherwise, for the use of these photographs. If you do not authorize or have concerns, please explain by writing your concerns and requests on this form. Please Note: If during your examination we find that you have periodontal problems, we will not be able to perform a regular cleaning. Instead, we will have to perform a deep scaling (cleaning) which is an additional fee if not covered by your insurance. All Holistic Biologic Dental Services such as Lasers, Bio Stimulation, PRF, Desensitizers, Irrigations, Mercury Safe Removal, Biocompatible material usage, Zirconia upgrade, Ceramic Upgrade, ALF, Neuromuscular TMJ Jaw Orthopedic treatment, upgraded Cosmetic services and Ozone therapy are not covered by insurance. you responsible for any related fees. You understand that you are waiving your insurance plans guidelines and you release all providers at Dental Excellence Integrative Center from the contractual terms of your plan.

Patient or Guardian Signature:

Printed Name of Patient or Guardian: Today’s Date: _________________

Applicable Policies





HIPAA OMNIBUS RULE

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims. HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA: First Name Only Proper Surname Other ___________________________ PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION: (This includes step parents, grandparents and any care takers who can have access to this patient’s records): Name: __________________________ Relationship: ______________________________ Name: __________________________ Relationship: ______________________________ --------------------------------------------------------------------------------------------------------------------------------- I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA: Cell Phone Confirmation Text Message to my Cell Phone Home Phone Confirmation Email Confirmation Work Phone Confirmation Any of the Above I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA: Cell Phone Confirmation Text Message to my Cell Phone Home Phone Confirmation Email Confirmation Work Phone Confirmation Any of the Above I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS or NEW HEALTH INFO on behalf of Dental Excellence Integrative Center via: Phone Message

Text Message None of the above (opt out)

Email The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE. In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent. ________________________________ ________________________________ Date: __________________ Printed name of Patient Signature of Patient / Guardian of Patient ________________________________ ________________________________ Date: __________________ Guardian / Legal Representative Signature of Patient / Guardian of Patient Office Use Only As Privacy Officer, I attempted to obtain the patient’s (or representatives) signature on this Acknowledgement but did not because: It was emergency treatment _____ I could not communicate with the patient _____ The patient refused to sign _____ The patient was unable to sign because _____ Other (please describe) ____

____________________________________________ Signature of Privacy Officer (Office Personnel)


patient information · patient survey medical history would you like to hear about homeopathic...

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