Medical and Dental Health History FormÂ
Our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only, will never be used to discriminate, and will be kept confidential subject to applicable laws. If you have any questions or are unsure how to answer a question, we’d be happy to assist you - please ask!Â
Are you ALLERGIC to or had a bad reaction to any of the following (check all that apply): *
Check off any of the following MEDICAL CONDITIONS that you had or have at the present: *
The ADA and AHA recommend premedication for patients with the following ONLY. If you have none of the issues and your surgeon recommends antibiotics for life, we have paperwork you can review and we request them to prescribe for you.
FINANCIAL AND CANCELLATION POLICY
Please check each statement once you have reviewed it*
MAJOR SURGERIES OR HOSPITAL VISITS
HIPAA ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESÂ
I have reviewed a copy of this office’s Notice of Privacy Practices and have had full opportunity to read and consider the contents. I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.Â
Note: If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information.Â
Right to Revoke: You have the right to revoke this consent at any time by giving us written notice of your revocation. Revocation will not affect any action we took in reliance on this consent before we received your revocation. Please understand that revocation may make thorough treatment difficult and we may decline to treat you or to continue treating you if you revoke this consent.
Authorization: I have reviewed the information on this form, understood it, and it is accurate to the best of my knowledge. I understand that this information will be relied upon by the dentist and staff to help determine appropriate and healthful dental treatment. I acknowledge that my questions, if any, about inquiries have been answered to my satisfaction. I will not hold my dentist, or any other member of the staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. If there is any change in my medical status I will inform the dentist.