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Welcome to Our Practice - Please Tell Us About Yourself
Today's Date
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First Name
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Middle Initial
Last Name
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Preferred Name
Date of Birth
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Male
Female
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I have NOT scheduled an appointment yet.
I have already scheduled an appointment, for the date of:
I have already scheduled an appointment, for the date of:
If under 18, person responsible for the account:
Social Security Number
Address
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City
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State
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Zip Code
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Home Phone
Work Phone
Cell Phone
Email Address
Employer
Occupation
Marital Status
Single
Married
Divorced
Widowed
Domestic Partner
Preference for Appointment Confirmation, Check Any That Apply
Phone
E-Mail
Text Message
If texting, the name of service provider
How did you hear about us?
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Insurance Information
Subscriber Name
Relationship to Patient
Employer
Subscriber Date of Birth
Insurance Company Name
Insurance Company Phone Number
Insurance ID Number
Group Number
Social Security Number
Secondary Insurance Information
Subscriber Name
Relationship to Patient
Employer
Subscriber Date of Birth
Insurance Company Name
Insurance Company Phone Number
Insurance ID Number
Group Number
Social Security Number
Medical History
Do you have a personal physician?
Yes
No
Date of last visit
Current Physician's Name
Physician's Phone Number
Are you currently under care of a physician?
Yes
No
If yes please explain
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Have you had any surgical procedures?
Yes
No
If yes please explain
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Have you had an adverse reaction to any medication or substance?
Yes
No
If yes please explain
0/255 characters
Are you taking any medications?
Yes
No
If yes please detail
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Please check any conditions that apply
Abnormal Bleeding
Alcohol Abuse
Allergies
Anemia
Angina Pectoris
Arthritis
Artificial Heart Valve
Artificial Joints
Asthma
Blood Transfusion
Cancer
Chemotherapy
Cold Sores
Colitis
Congenital Heart Defect
Cortisone Medicine
Diabetes
Difficulty Breathing
Drug Abuse
Eating Disorder
Emphysema
Epilepsy
Facial Surgery
Fainting Spells
Fever Blisters
Frequent Headaches
Glaucoma
HIV + AIDS
Heart Attack
Heart Murmur
Heart Surgery
Hemophilia
Hepatitis A
Hepatitis B
Hepatitis C
High Blood Pressure
Implant (any type)
Jaundice
Joint Replacement
Kidney Problems
Liver Disease
Low Blood Pressure
Mitral Valve Prolapse
Pacemaker
Psychiatric Problems
Radiation Therapy
Rheumatic Fever
Seizures
STD
Shingles
Sickle Cell Disease
Sinus Problems
Sleep Apnea
Stroke
Transplant (any type)
Thyroid Problems
Tuberculosis
Tumors
Ulcers
Venereal Disease
Do you have or have you had any disease, condition or problem not listed?
Yes
No
If yes please explain
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If Female, are you?
On Birth Control
Nursing
Pregnant
Name of person to contact in case of an emergency
Emergency contact phone number
Dental History
How may we help you today?
Your current dental health is?
Good
Fair
Poor
When was your last dental visit?
When was your last dental cleaning?
Do you have any current x-rays from another office? If answering yes to any below please have x-rays emailed to drallen@myomahadentist.com before day of appointment.
Yes Bitewings less than 1 year old.
Yes Panoramic less than 3 years old.
No
Have you had any difficulty or unfavorable experiences with previous dental work?
Yes
No
If yes, please explain
Why did you leave your previous dentist?
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How can we accommodate you better during your visit?
Are you currently in pain?
Yes
No
Do you require antibiotics before treatment?
Yes
No
How often do you brush your teeth?
How often do you floss?
Do you have problems with bad breath?
Yes
No
Do you have problems with bleeding gums?
Yes
No
Do you use any forms of tobacco?
Yes
No
Have you ever had gum treatment?
Yes
No
Please check any of the services you would like to further discuss with Dr. Allen during your visit.
Deep Gum Cleaning
Sealants
Tooth Colored Fillings
Porcelain Crowns
Veneers
Bonding
Bridges & Partials
Dentures
Implants
Inlays/Onlays
Root Canal Therapy
Extractions
Gum Contouring
Teeth Grinding/TMJ
Mouth Guards
"Bite" Adjustments
Invisalign (clear braces)
Zoom Teeth Whitening
"All Natural" Dentistry
Biocompatibility Testing
Nitrous Oxide (laughing gas)
Have you ever had?
Orthodontic treatment (braces)
Oral Surgery
A mouth guard
Your "bite" adjusted
An injury to the mouth or head
Do You?
Clench or grind your teeth while asleep
Snore or suffer from sleep apnea
Mouth breath while awake or asleep
Bite your lips or cheeks regularly
Hold foreign objects with your teeth (pencils, pipe, pins, nails, fingernails)
Have tired jaws, especially in the morning
Have you ever experienced?
Clicking or popping of the jaw
Pain (joint, ear, side of face)
Headaches, neckaches, or shoulderaches
Sore muscles (neck, shoulders)
History of trauma to your jaw
Difficulty opening or closing the mouth
Difficulty chewing on the either side of mouth
Do you like your smile?
Yes
No
Are you happy with the color of your teeth?
Yes
No
If you could change anything about your smile and teeth, what would it be? (If you had a magic wand)
Notice of Privacy Practices
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
The Health Insurance Portability & Accountability Act of 1996 (“HIPAA”) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPAA” provides penalties for covered entities that misuse personal health information.
As required by “HIPAA”, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.
Treatment means provided, coordination, or managing health care and related services by one or more health care provider. An example of this would bee teeth cleaning services. Payment means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for the payment. Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be internal quality assessment review.
We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be if interest to you. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer.
The right to request restrictions on certain uses and disclosures of protected health information, included those related to disclosures to family members, other relatives, close personal friends or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction we must abide by it unless you agree in writing to remove it.
The right to reasonable requests to receive confidential communications of protected health information from us by alternative means at alternative locations.
The right to inspect and copy your protected health information.
The right to amend your protected health information.
The right to receive an accounting of disclosures of protected health information.
The right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of you protected health information and to provide you with notice of your legal duties and privacy practices with respect to protected health information.
The notice is effective as of April 14, 2003 and we are required to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.
You have recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with our office, or with the Department of Health Human Services, Office of Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.
Please contact us for more information.
For more information about HIPAA or to file a complaint:
The U.S. Department of Health & Human Services
Office of Civil Rights 200 Independence Avenue, S.W.
Washington, D.C. 20201
Toll Free: 1-8777-696-6775
Notice of Privacy Practices Acknowledgement
I have read and understand the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that I can receive a paper copy of the Notice of Privacy Practices upon request.
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Medical and Dental History Acknowledgement
I understand that the information in the Medical History and Dental History I have given is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence, and that you have my permission to ask the respective health care provider or agency for further information if needed. It is my responsibility to inform this office of any changes in my health or medications.
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Consent for Treatment
I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of my dental needs. Upon such diagnosis we will provide a treatment plan specific to your needs and wants of the individual. I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
Regarding Insurance
If you have dental insurance we do require your co-pay and deductible to be paid in full at the time of visit. The balance is your responsibility whether your insurance company pays for your treatment of not. We will gladly process your claims provided that you give us accurate, up to date insurance information. It is your responsibility to inform us of any changes in your insurance coverage. Your insurance policy is a contract between you and your insurance company. We are not a party to the contract. Please be aware that although we will call and verify your coverage, some and perhaps all, of the services provided may be non-covered or not considered reasonable/necessary under that policy your employer has selected. It is the insurance company that makes the final determination of your eligibility and payment. You agree to pay any portion of the charges not covered by insurance.
Financial Policy
All monies are due in full prior to or at the time services are rendered. We accept cash, check, credit card (this includes HSA’s and Flex Accounts) and Care Credit. Though we do not anticipate the following circumstances we must, by law, make all patients aware of the following:
Finance Charge: A finance charge will be imposed on each item of your account, which has not been paid within sixty (60) days. The finance charge will computed at the rate of 1.5% per month. Past Due Accounts: If your account becomes past due, we will take necessary steps to collect this debt. If we have to refer your account to a collection agency, you agree to pay all the collection fees that are incurred. If we have to refer collection of your account to a lawyer, you agree to pay all lawyers’ fee which we incur plus all court cost. In case of suit, you agree the venue shall be in Omaha, NE and Douglas County.
I have read and understand the Consent for Treatment, Regarding Insurance and Financial Policy.
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