Patient Forms :: Alternative Dental Care

Patient First Name

Patient Last Name

Patient’s Home Address:

Phone number

Social Security Number

Emergency Contact Name

Emergency Contact Phone number

Emergency Contact Relation to Patient

Name of Special Care Facility

Facility Address:

Facility Contact Person

Facility Contact Title

Facility Phone

Name of Physician

Physician Address

Physician Phone number

Name of Last Dentist

Last Dentist Address

Last Dentist Phone number

Date of Last Dental Visit

Date of Last Dental Cleaning

Some illnesses and drugs may make an alteration to patient treatment. In order to provide the best possiblecare, please complete this area by checking any box that applies or filling in specific lines:

Antibiotics

Insulin

Hormones

Tranquilizers/Antidepressants

Steroids

Diet Supplements

Blood Thinner/Anticoagulants

Blood Pressure Medication

Any Heart Medication

Are there any known allergies? If so List:

Check any conditions that apply:

History of Rheumatic Fever

High Blood Pressure

Heart Attack

Stroke

Pacemaker

Diabetes

Hearing impaired

Hepatitis/jaundice/liver disorder

Recent blood transfusion

Kidney disorder

Persistent/chronic cough

Tuberculosis

Lung disorder

Cancer history

Radiation/chemo history

Ulcer

GERD/reflux

Osteoporosis

Arthritis

Epilepsy/convulsions

Impaired vision

Psychiatric treatment

Alzheimer’s disease/dementia

Cerebral palsy

Multiple Sclerosis

Parkinson’s Disease

Hip, knee or any joint replacement?

if so, have antibiotics every been required for dental care?

Do you have any disease, condition, or problem not listed?

Please list name of antibiotics prescribed for dental care, and the doctor that prescribed:

List all medications prescribed:

Name of Responsible Party

Mailing/Billing Address

Email of Responsible Party

Relationship to Patient

I am the patient and/or hold Health Care Power to Attorney for patient

All Fees are ultimately the responsibility of the “Responsible Party” within 30 days of service.

In accordance with the Privacy Regulations created by the Health Insurance Portability and Accountability Act of 1996 (HIPPA), we are required to maintain the confidentiality of your health information.We realize these laws are complicated, but we must provide you with the following important information that describes how we may use or disclose your protected health information to carry out treatment, payment of health care operation and for other purposes that we are permitted by law. We will use and disclose your protected health information to provide, coordinate, or manage your dental care and any related services. For example: your health/dental information may be provided to a dentist whom you have been referred to ensure that the dentist has the necessary information to diagnose and treat you. In addition, we may disclose your protected health information periodically to another dentist, physician or health care provider who becomes involved in your case. We may disclose information about you in order to obtain payments for services rendered. Such disclosures may be made to you, an insurance company, responsible party or third party. We may also tell your health plan about a treatment you are going to receive to obtain prior approval or to determine whether your plan will cover the treatment. By signing below, you are consenting to dental hygiene services provided by Susan Dragoo, RDHAP, Alternative Care Dental Hygiene Practice or an Associate RDHAP of Susan Dragoo, RDHAP, Dental Hygiene Practice, and agree that you will be responsible for all payments (You also agree that Susan Dragoo, Alternative Care Dental Hygiene Practice may review your medical records, and that a photo may be taken for our files.

Forms for Service