Joseph Zolinski, DDS Patient Forms

Joseph Zolinski DDS - Patient Forms

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PATIENT INFORMATION

First Name

Last Name

Preferred Name

Phone

Social Security #

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Sex

Male

Female

Age

Birthdate

MM slash DD slash YYYY

Status

Married

Divorced

Widowed

Single

Employed by

Occupation

Employer's Phone

Employer's Email

Employer's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Would you like to receive text message reminders?

Yes

Would you like to receive email reminders?

Yes

SPOUSE OR RESPONSIBLE PARTY

Name

First Last

Relationship to patient

Phone

Social Security #

Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Employed by

Employer's Phone

Employer's Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Please list all family members cared for in our office

DENTAL INSURANCE

Company name

Phone #

Group ID #

DENTAL / MEDICAL HISTORY

In case of an emergency, notify

Phone #

Physician

Last physical

Phone #

Pharmacy

Phone #

Please list all medications presently taking

Do you have allergies or adverse reactions to any medication?

Yes

If "Yes", please list all medications:

Last dental visit

Have you had any previous dental treatment problems

Do you have or have you had any of the following: please answer by putting a checkmark by each question.

Heart Failure

Heart Disease

Heart Murmur

Congenital Heart Lesions

Angina Pectoris

Artificial Heart Valve

Heart Pacemaker

Heart Surgery

High Blood Pressure

Rheumatic Fever

Stroke

Neurological Problems

Psychological Problems

Cortisone or Steroids

Thyroid Disease

Glaucoma

Anemia

Bleeding Problems

Hemophilia

Kidney Trouble

Hepatitis A(infectious)

Hepatitis B(serum)

Liver Disease

Jaundice

Ulcers

Tumors/Growths

X-ray treatments

Cancer or Chemotherapy

Artificial Joints

Pain in Jaw Joint

Epilepsy, Seizures

Emphysema

Tuberculosis(TB)

Asthma

Sinus Trouble/Allergies

Diabetes

HIV Positive

AIDS

Venereal Disease

Cold Sores, Fever Blisters

Do you use tobacco

Do you drink alcohol

Are you pregnant

I hereby grant permission for dental treatment to be performed and will assume all responsibilities connected with such treatment. A broken appointment is a loss to everyone. Please inform us 48 hours in advance if you are unable to keep your appointment.

Patient’s (or Legal Guardian’s) Signature

Date

MM slash DD slash YYYY

EXAMINATION QUESTIONAIRE

Name

How long has it been since you've had a dental exam?

How long has it been since you've had dental x-rays?

How long has it been since you've had a professional cleaning?

What prompted you to seek dental care at this time?

Are you satisfied with your past dental experiences?

Have you had your wisdom teeth removed?

Have you worn braces in the past?

Do you wear an appliance (retainer/night guard/snore guard/CPAP)?

How often do you usually brush?

How often do you usually floss?

How often do you usually have a professional cleaning?

Please check any of the following that pertain to you:

Bleeding gums

Chewing sensitivity

Clenching/Grinding

Congestion

Crooked teeth

Discoloration

Fatigue

Frequent headaches

Hot/Cold Sensitivity

Joint discomfort

Poor sleep

Seasonal allergies

Snoring

Tender gums

Throbbing pain

If you checked any of the above items, please explain.

Is there anything you would like to change about the appearance of your smile? Please check any of the following areas of interest:

Whitening

Invisalign

Cosmetic Dentistry

Crowns

Veneers

Bonding

Snore Guard

Night Guard

On a scale of 1-10, 10 being very important, how important are your teeth?

Whom may we thank for your referral?

I give my permission to use photos of my smile, teeth, and gums in any marketing including, but not limited to website publication, Facebook, print advertisements, newspapers, magazines, electronic media, phonebooks, brochures, fliers and presentations.

Yes

Signature

Date

MM slash DD slash YYYY

FINANCIAL/ INSURANCE INFORMATION

Full name of policy holder:

Social Security # of policy holder:

Date of birth of policy holder:

Dental insurance company name and mailing address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Phone#:

Group ID#:

I hereby grant permission for dental treatment to be performed and will assume all responsibilities connected with such treatment.

Patient's (or Legal Guardian's) Signature

Date

MM slash DD slash YYYY

Due to the Health Insurance Portability and Accountability Act, our privacy policy is now available to our patients. It informs you how we use and disclose your health information for treatment, payment, and healthcare operations. This will be done at the patient's request. A copy of our policy will be available in the office waiting room for patient's review. Your signature is your acknowledgement of this HIPAA policy.

Patient signature

Date

MM slash DD slash YYYY

By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. You have a right to read our Notice of Privacy Practices before you decide whether to sign this consent.

Patient signature

Date

MM slash DD slash YYYY

Thank you for your cooperation in complying with the Federal HIPAA Regulations. This privacy of your health information is important to us. At your request, we will by happy to provide you with a copy of this consent form.

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