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

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 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?

What were you told to premedicate for?

Have you had an ARTIFICIAL HEART VALVE REPLACEMENT?

When was your heart valve replaced?

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

When was CVC placed and why was it placed?

Have you had a stroke?

When was your stroke?

Have you had a heart attack?

When was your 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 cancels 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 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. 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. 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. 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.

Responsible Party Full Name & Relationship to Patient

Responsible Party Signature

Date