Patient Information
Health Questionnaire
Financial Agreement
Notice of Privacy Practices

Patient Information

Signature:

Health Questionnaire

Please answer each question and circle Yes or No where applicable.

These questions are for your benefit and to assure that our treatment will take into consideration your past and present health status. Some questions may seem unrelated to your dental condition, but they are all associated with proper oral health care.

Are you in good health? *

Date of last physical exam

Are you now under the care of a physician? *

If so, what is the condition being treated

Have you ever had any serious illness or operations? *

If so, what illness or operations

Have you ever been hospitalized? *

If so, what was the problem?

Anemia *

Herpes *

Stroke *

Ulcers *

Diabetes *

Arthritis *

Asthma *

Cancer *

Seizures *

Hay Fever *

Headaches *

Implants *

Venereal Disease *

Glaucoma *

Tonsillitis *

Hemophilia *

Cold Sores *

Emphysema *

Rheumatism *

Heart Attack *

Bruise Easily *

Head Injuries *

Heart Failure *

Scarlet Fever *

Sinus Trouble *

Sleep Apnea *

Snoring *

Heart Murmur *

Liver Disease *

Blood Disease *

Heart Ailments *

Blood Transfusion *

Cerebral Palsy *

Drug Addiction *

Kidney Disease *

Chemotherapy *

Stomach Ulcers *

HIV or Aids *

Angina Pectoris *

Mental Disorder *

Thyroid Disease *

Fainting Spells *

Rheumatic Fever *

Tuberculosis *

Mitral Valve Prolapse *

Low Blood Sugar *

Joint Replacement *

Nervous Disorders *

Tumors or Growths *

Allergies or Hives *

TMJ *

Pain in Jaw Joint *

Artificial Prosthesis *

Sickle Cell Disease *

Cortisone Medicine *

Allergies to Metal *

Excessive Bleeding *

Radiation Treatment *

High Blood Pressure *

Low Blood Pressure *

Respiratory Disease *

Epilepsy or Seizures *

X-Ray or Cobalt Treatment *

Psychiatric Treatment *

Hepatitis or Jaundice *

Difficulty Swallowing *

Congenital Heart Lesions *

Osteoporosis *

Are you taking Humira *

Do you have any disease, condition or problem not listed that you think we should know about? *

Do you wear a cardiac pacemaker or have you had heart surgery? *

Do you smoke? *

How much do you smoke?

Do you use recreational drugs? *

What kind of recreational drugs do you use?

Have you ever taken any of the following?

Fen Phen *

Redux *

Fosomax *

Zometa *

Actonel *

Boniva *

Aredia *

Diet Drugs *

Are you pregnant? *

If yes, how many months?

Are you a victim of domestic violence? Do you need help? *

Explain:

Have you ever had any unfavorable reaction to dental anesthetic? *

Are you sensitive to epinephrine? *

Have you had any serious trouble associated with any previous dental treatment? *

Explain:

Does dental treatment make you nervous? *

Would you desire to be pre-sedated? *

Do you snore or does anyone in your family snore? *

Do you feel tired during or at the end of the day? *

Morning Headaches *

Forgetfulness *

Insomnia *

Need To Urinate During The Night *

Difficulty Concentrating *

TMJ Disorder *

Bruxism/Grinding Teeth *

Need Caffeine Throughout The Day *

Frequent Nightly Awakenings *

Regular Use Of Sleep Aid *

Frequent Neck Soreness *

Difficulty Initiating Sleep *

Dry Mouth At Night /Awakening *

CURRENT MEDICATIONS/SUPPLEMENTS AND ALLERGIES

Are you allergic to?

Penicillin? *

Erythromycin? *

Tetracycline? *

Nsaids? *

Latex? *

Shellfish? *

Iodine? *

Other Allergies:

All services are rendered and accepted under the terms and conditions printed on the reverse hereof:

Authorization must be signed by the patient, or by the nearest relative in the case of a minor or when the patient Is physically or mentally incompetent To the best of my knowledge, all of the preceding answers are true and correct If I ever have any change In my health or If my medications change, I will , without fail, inform the doctor at my next appointment

Financial Agreement

Welcome! Thank you for choosing us as your dental health care providers!

Our goal is to provide you and your family with optimal dental care...

Financial Agreement

Treatment plans are good 6 months from the date issued. After that period fees and financial arrangements are subject to change...

Optional Payment Terms

Pay in full cash discount: We offer a 5% accounting courtesy for all services over $500 that are paid in full on the date of service for those who do not have dental insurance.
Pre-Pay discount: If you choose to prepay for services 48 hours prior to your reserved appointment we will extend a 10% courtesy discount with cash or check...
In-office payment plan: We offer a courtesy 3 month interest-free automatic payment plan with a credit card on file. Arrangements must be made prior to your reserved appointment...
Term Loan: By arrangements with CARECREDIT and/or THE LENDING CLUB we can offer patients upon approval, an interest-free term loan (up to 24 months) with no down payment, no annual fee and no prepayment penalty.

For Our Patients with Insurance

As a courtesy to our insured patients, we obtain your plan benefits and submit claims to your insurance company free of charge...

I hereby authorize my insurance company to directly reimburse Redondo Beach Dental Group for services rendered to me under my insurance policy.

Appointments

In order to serve you better and keep the cost of dental care down, we try to maintain an efficient appointment system...

When you schedule an appointment at our office, we consider it a commitment that the time will work with your schedule...

We do not penalize for unavoidable situations and emergencies...

We will attempt to communicate with you in multiple ways to remind you of your reserved appointments...

Please indicate your understanding and acceptance of these scheduling and financial policies by signing below.

Notice of Privacy Practices

HIPAA Privacy Notice

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review it carefully...

The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper or orally, are kept properly confidential...

As required by "HIPAA," we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information...

We may use and disclose your medical records only for each of the following purposes: treatment, payment, and health care operations...

Your Rights with Respect to Your Protected Health Information:

The right to request restrictions on certain uses and disclosures of protected health information...
The right to reasonable request to receive confidential communications of protected health information from us by alternative means or alternative locations...
The right to inspect and copy your protected health information...
The right to amend your protected health information...
The right to receive an accounting of disclosures of protected health information...
The right to obtain a paper copy of this notice form upon request...

This notice is effective as of 11-18-2015 and we are required to abide by the terms of the notice of Privacy Practices currently in effect...

You have recourse if you feel that your privacy protection has been violated...

For more information about HIPAA or to file a complaint:

The US Department of Health & Human Services Office of Civil Rights
200 Independence Avenue, S. W.
Washington, D.C. 20201
Toll-Free: 1-877-696-6775

Patient Acknowledgment:

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information...

I understand that this information can and will be used to:

Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly...
Conduct normal healthcare operations such as quality assessments and physician certifications...

I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information...

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health care operations...

I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices...

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient Name *

Relationship to Patient *