INNOVATIVE PERIODONTICS & DENTAL IMPLANTS

PATIENT INFORMATION

First

Last

Preferred Name

Birthdate

Age

Address

City

Zip Code

Cell

Home

Work Phone

Extension

Employer

Occupation

Name & Address of School if Student

Spouse Name

Date Of Birth

Cell Phone

Spouse Employer

Work Phone

Whom may we thank for referring you?

PERSON RESPONSIBLE FOR ACCOUNT

Name

Relation

Address

City

Zip Code

Cell

Home

Employer

Work Phone

In case of emergency, please contact:

Name

Relation

Best Contact #

DENTAL INSURANCE INFORMATION

Do you have insurance?

Insurance Company Name

Group/Policy #

Employee Name

Relation

Date Of Birth

SS# or ID#

Employer

Work Phone

Do you have Secondary Insurance?

Insurance Company Name

Group/Policy #

Employee Name

Relation

Date Of Birth

SS# or ID#

Employer

Work Phone

HIPAA AUTHORIZATION

By way of my signature, I provide this practice with my authorization and consent to use and disclose my protected health information (PHI) for the purposes of treatment, payment, and health care operations as described in the Privacy Notice. (Health Insurance Portability & Accountability Act)

Signature

Date

Who may we contact to discuss your personal health information (PHI)? i.e.; confirming appointments, financial, prescriptions, treatment plans or instructions. When applicable.

TREATMENT CONSENT

I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and any other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of my/my dependent’s periodontal needs. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and the doctor, including the use of human and animal graft derived materials, PerioLase Nd:YAG and diode setting laser assisted procedures, use of titanium based dental implants and components, amalgams and any other dental/periodontal material, and to employ assistance as required to provide proper care. I consent to the use of anesthetics, sedatives, and other medication as necessary for my treatment.

I fully understand that using anesthetic agents embodies certain risks.

FINANCIAL POLICY ACKNOWLEDGEMENT

I agree to be responsible for payment of all services rendered on my or my dependant’s behalf, regardless of possible insurance coverage. Payment is due at the time of service unless other arrangements have been made in advance. A 1.58% finance charge (18% APR) may be charged on any balance over 60 days old.

The cost estimates I am given are only estimates and unforeseen events may cause a change in the cost for my treatment.

In the event financial arrangements are not adhered to, I understand the entire account balance will be considered delinquent and will be due and payable immediately. I agree to be responsible for any reasonable collection costs or attorney fees incurred in collecting a delinquent account.

I hereby authorize payment of dental benefits otherwise payable to me to be paid directly to the dental provider.

APPOINTMENT POLICY ACKNOWLEDGEMENT

The appointment time I schedule will be reserved for me and my prompt arrival will facilitate my treatment being completed in a timely manner. I am responsible for keeping my scheduled appointment regardless of any courtesy call or card I may or may not get.

Prior notice of 14 DAYS is required to reschedule or cancel a periodontal surgery appointment; 48 HOURS notice is required to reschedule or cancel a non-surgical appointment. The office utilizes a 24-hour answering system I may use for after-hours messages.

A broken-appointment fee of up to 50% of the treatment amount scheduled for any appointment missed or cancelled without the above-required notification may be applied. Exceptions in this policy can only be determined on an individual basis.

By way of my signature, I understand and agree to the terms in the above appointment and financial policies and treatment consent.

Patient Signature

Date

Parent/Responsible Party Signature

Relationship

HEALTH HISTORY

In order to provide your periodontal care in a safe and efficient manner, we ask you to update your Health History on a regular basis. Please review each question carefully and answer as completely as possible.

Physician Name

If Kaiser Patient- Medical Record Number

Physician Address

Physician Phone

Date of Last Physical Exam

Do you require antibiotic premedication for dental visits?

Note

Have you been a patient in a hospital during the past two years?

Note

Are you now taking any prescription or non-prescription medications?

Please list current medications:

Are you now taking any vitamins, herbal or homeopathic supplements?

Please list current supplements:

Have you had an adverse or allergic reaction to any medications including antibiotics (like Penicillin), anesthesia (local numbing or general sedation) or analgesics (pain medication)?

If yes, please list medications:

Please describe reaction:

Do you currently or have a history of:

How much? When did you stop?

Do you feel anxious or nervous about dental treatment?

Note

Have you ever had a negative dental experience?

Note

Type of tooth brush?

How often used?

Have you ever had orthodontic treatment (BRACES)?

When and with whom?

Do you wear:

Other aids? (i.e. floss, water-pik) & how often used?

Have you ever had periodontal scaling & root planing or surgery?

Text

When and with whom?

Women: Are you pregnant?

What month are you in?

Women: Are you taking birth control pills?

Please indicate if you have a history of, or currently have, any of the following medical conditions:

History of Alcohol or Drug Abuse

Note

Anemia/Blood Disorder

Note

Angina/Chest Pains

Note

Ankle Swelling

Note

Arthritis/Rheumatism

Note

Artificial Joints

Note

Asthma

Note

Blood Clotting Problem

Note

Cancer: History of/or currently undergoing treatment:

Type of cancer:

Type of treatment:

Diabetes

Please specify:

Last HbA1c value, when taken?

Epilepsy/Seizures

Date of last episode?

Fainting/Dizzy Spells

Note

Glandular/Thyroid Disease

Checkbox

Glaucoma

Note

Heart Disease or Heart Attack

Please specify when and treatment

Heart Murmur or Congenital Heart Defect

Note

Hepatitis/Liver Disease

Treated?

Herpes

Note

High or Low Blood Pressure

HIV Positive/AIDS

Note

Immune System Disease

Kidney Disease

Note

Latex Allergy

Note

Osteoporosis

Bisphosphonate Use

Pacemaker/Artificial Heart Valve

Note

Radiation Treatment

Note

Respiratory Disease

Note

Rheumatic Fever

Note

Seasonal Allergies

Note

Shortness of Breath

Note

Sinus Problems

Note

Sleep Apnea

Are you compliant with sleep aid?

Stroke

Last episode?

TMJ/Jaw Pain

Note

Tumors or Growths

Treated with:

Ulcers

Note

Do you have any medical condition or concern not listed above?

If yes, please explain

I understand the above information is necessary to provide me with periodontal care in safe and efficient manner. I have answered all questions truthfully and to the best of my knowledge.

Patient Signature

Date

SIGNATURE OF DOCTORS:

J. Jay Uemura, D.D.S.

Philip Vassilopoulos, D.D.S., D.M.D.

Raime Shah, D.D.S., M.S.