OperaDDS - Form

Existing Patient Update

Patient's First Name

Patient's Last Name

Patient's Date Of Birth

Sex

Name / Relationship to Patient

POA Full Name & Relationship to Patient

POA Street Address, City, State, Zip

POA Cell Phone

POA Home Phone

POA Email

Fiduciary Company

Fiduciary Street Address, City, State, Zip

Fiduciary Case Manager

Fiduciary Phone

I am stating that I am self responsible and I authorize Smiels by Delivery to contact the person I am appointing as my emergencey contact to verify that status of me being self responsible.

Emergency Contact Person & Relationship to Patient

Emergency Contact Phone

Emergency Contact Email

The HIPAA recommended form of conveying emailed patient information is via encrypted email, however, you can choose to convey information with our office via conventional email. Please choose which form of email you would prefer:

Name of Physician

Physician's Phone

Are you being treated by a physician?

What are you being treated for?

Have you been hospitalized in the last 5 years?

Date of Hospitalization

What were you hospitalized for?

Name of Pharmacy

Pharmacy Phone

Are you currently taking medications?

Medication List

File Uploader

Upload or drag files here

Do you have any allergies to medications?

What medication allergies?

If you are taking a PRESCRIPTION BLOOD THINNER, (such as Coumadin, Eliquis, Plavix, Pradaxa or Xarelto), we will need to contact your physician to get medical orders for their instructions prior to dental extractions.

Are you currently taking a PRESCRIPTION BLOOD THINNER? (not OTC aspirin)

If you have EVER TAKEN A BISPHOSPHONATE medication, (such as Actonel, Boniva, Fosamax, Reclast or Zometa), for osteoporosis or Paget's disease, we will need to consult with your physician to determine if you will need to be referred to an oral surgeon for dental extractions.

Have you EVER taken BISPHOSPHONATES?

When did you start and finish bisphosphonate use?

Have you been diagnosised with Alzheimer's?

What stage of Alzheimer's?

Do you have an ARTIFICIAL JOINT?

If so, what joint and when was it placed?

Have you ever been instructed to PREMEDICATE WITH AN ANTIBIOTIC PRIOR TO A DENTAL APPOINTMENT FOR A NON-INFECTION CONDITION?

What was the non-infection condition? (ie: artifical joint, artificial heart valve, etc)

Have you had an ARTIFICIAL HEART VALVE REPLACEMENT?

Month/year of heart valve replacement?

Do you currently have a CENTRAL VENOUS CATHETER (CVC)?

When was CVC placed and why was it placed?

Have you had a stroke?

Month/year of stroke?

Have you had a heart attack?

Month/year of heart attack?

AIDS/HIV

Cancer

Diabetes

COPD

Parkinson's

Heart Disease

Oxygen Use

Trach in Place

Organ Transplant Recipient

Head/Neck Radiation

Current Diaylsis

High Blood Pressure

Low Blood Pressure

Congestive Heart Failure

Sedative Request

By signing below, I certify that all of the above information is true to the best of my knowledge. I understand that I am required to complete Smiles by Delivery's update form on a yearly basis. I also understand that it is my responsiblity to request an update form prior to any dental appointment, if there are any changes, including but not limited to medical changes, status changes regarding responsibility and care, or any other account changes.

As validated by your signature on the bottom of this form, you understand and agree that:
Payment is due at time of service. If the financially responsible person is not present at the appointment, payment will be due prior to the appointment.

A cancelation fee of $99 may be charged for patients who miss or cancel an appointment without 24 hour notice. If a patient cacels three appointments, the patient may be dismissed from our practice and asked to find another dentist.

A returned check fee of $50 will be applied to your account and must be payable from you for each check payment returned to us by your bank.

Dental Insurance: By signing below, I authorize Smiles by Delivery to submit claims for benefits, for services rendered or for services to be rendered, without obtaining my signature on each and every claim. It is my responsibility to verify whether my insurance is an out-of-network or in-network plan and if my insurance is active. I understand that Smiles by Delivery can assist me in verifying this information.

PPO Out-of-Network Plans: Dental insurance is a contract between the patient, their employer (if applicable) and the insurance provider. Submitting claims for payment to the insurance provider is a courtesy provided by Smiles by Delivery, not an obligation. I understand that if Smiles by Delivery is out-of-network with my dental insurance plan, my insurance is not accepted as a form of payment.

In-Network Plans: If Smiles by Delivery is in network with my dental insurance, I authorize my insurance benefit to be directed to Smiles by Delivery. Ultimately, I am responsible for any treatment that is unpaid by the insurance provider.

*By signing below, I consent to any recommended x-rays, teledentistry exams, clinical exams, cleanings (prophy or fullmouth debridement), and fluoride treatments. I understand that a licensed dental hygienist or licensed affiliated practice dental hygienist will be providing the dental hygiene services. Dental hygiene care alone does not take the place of a dental examination or complete dental care. The teledentistry exams, clinical exams, dental diagnosis, treatment plans and restorative treatments are provided by licensed dentists, which may follow the appointment with the hygienist.

Responsible Party Full Name & Relationship to Patient

Responsible Party Signature

Date

rev6/25/2020