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Home
About
Our Office
Meet the Doctor
Our Staff
Philosophy
Technology
Services
Bonding
Crowns and Bridges
Dental Cleaning
Dentures
Extractions
Fillings
Gum Treatments
Implant Restoration
Night Guards
Oral Hygiene
Root Canal
Sealants
Sedation Dentistry
Veneers
Whitening
Wisdom Teeth
Patients
New Patients
Insurance / Billing
Smile Gallery
Contact
Make a Payment
New Patient Registration
Home
»
New Patients
»
Patient Intake Form
Patient Intake Form
1
PATIENT INFORMATION
2
INSURANCE INFORMATION
3
DENTAL/MEDICAL HISTORY
4
MEDICAL HISTORY (Continued)
5
OFFICE POLICY
6
HIPAA
First Name
*
Middle
Last Name
*
Preferred Name
Date of Birth
*
Date Format: MM slash DD slash YYYY
Gender
*
Male
Female
Relationship Status
*
Married/Domestic Partner
Single
Address
*
Street Address
Address Line 2
City
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
Zip
Cell
*
Home
Work
Place of Employment
Social Security Number
Email
*
Whom may we Thank for referring you?
First
Last
Physician's Name
Phone
SPOUSE/PARTNER INFORMATION
Spouse's Name
*
First
Last
Social Security Number
Date of Birth
*
Date Format: MM slash DD slash YYYY
Cell
*
Place of Employment
IN CASE OF EMERGENCY, WHOM MAY WE CONTACT?
Name
*
Phone 1
*
Phone 2
Relationship to Patient
*
Insurance:
Do you have dental insurance?
*
Yes
No
Insurance company
*
Group #
Subscriber's First Name
*
Subscriber's Middle Name
Subscriber's Last Name
*
Subscriber's SSN/ID #
*
Subscriber's Date of Birth
*
Date Format: MM slash DD slash YYYY
Patient's relationship to Subscriber
*
Self
Spouse
Dependant
Do you have secondary dental insurance?
*
Yes
No
Secondary Insurance:
Insurance company
*
Group #
Subscriber's First Name
*
Subscriber's Middle Name
Subscriber's Last Name
*
Subscriber's SSN/ID #
*
Subscriber's Date of Birth
*
Date Format: MM slash DD slash YYYY
Patient's relationship to Subscriber
*
Self
Spouse
Dependant
Dental History
Do you have a specific dental problem or concern?
*
Yes
No
Have you had an upsetting experience in a dental office or do you feel nervous about having dental treatment?
*
Yes
No
Do you have TMJ problems? (Bruxing, grinding teeth / popping, clicking or discomfort around jaw joint)
*
Yes
No
Name of previous dentist where we may obtain prior x-rays, etc.:
Previous Dentist Phone
When was your last dental exam?
Medical History
Medical doctor's name
Mr.
Mrs.
Miss
Ms.
Dr.
Prof.
Rev.
Prefix
First
Last
Phone No.
Date of last physical exam:
Date Format: MM slash DD slash YYYY
Has your physician ever indicated that you should be pre-medicated with antibiotics prior to dental treatment?
*
Yes
No
Are you under a doctor’s care now?
*
Yes
No
Have you been hospitalized or had surgery in the last 5 years?
*
Yes
No
Have you had surgery or x-ray treatment for tumor, growth, or other condition of your mouth or lips?
*
Yes
No
Have you had abnormal bleeding associated with previous extractions, surgery, or trauma?
*
Yes
No
Do you or have you used tobacco products?
*
Yes
No
Are you currently pregnant?
*
Yes
No
If recently given birth, are you breastfeeding?
*
Yes
No
Are you taking any prescription or over-the-counter medications?
*
Yes
No
Please check any condition(s) that you have now, or have had in the past:
Cardiovascular Disease: (heart attack, coronary insufficiency, coronary occlusion, high/low blood pressure, arterioclerosis, stroke, pacemaker)
Heart Problems: prosthetic valve, endocarditis, congenital heart disease, transplant w/ valvulopathy
Rheumatic fever, mitral valve prolapse or heart murmur
Seizures, fainting spells or epilepsy
Blood disorder, anemia or slow clotting
Hyper- or hypothyroidism
Liver: Jaundice, Hepatitis A/B/C, Cirrhos
Kidney: Renal failure, Shunt, Dialysis
Tuberculosis
Glaucoma
Chemotherapy or radiation
Cold sores or herpes virus
Positive HIV, AIDS, or AIDS related complex
Frequent allergies, hives or rash
Do you have diabetes?
*
Yes
No
*
Have you ever been diagnosed with cancer?
*
Yes
No
Have you ever had a blood transfusion?
*
Yes
No
*
Do you have any Artificial prosthesis/implants? (joints, hip screws, etc.)
*
Yes
No
Is there any condition, not listed above, that we should know about?
*
Yes
No
Please check if you are taking any of the following medications:
Antibiotics or sulfa drugs
Medicine for high blood pressure
Tranquilizers
Aspirin
Digitalis or drugs for heart trouble
Anticoagulants (blood thinners)
Bisphosphonates (Boniva, Actonel, Fosamax, Skelid, or Didronel)
Antihistamines
Insulin (for diabetes)
Nitroglycerin
Are you currently taking any antidepressants?
*
Yes
No
Are you taking any other medication(s) not listed above?
*
Yes
No
Please check if you are allergic or have reacted adversely to any of the following medications:
Local anesthetics
Sulfa drugs
Aspirin, tylenol, ibuprofen
Barbiturates, benzodiazapines, sleeping pills
Penicillin or other antibiotics
Latex
Codeine or other narcotics (e.g. Tylenol 3, Vicodin, Percocet)
Are you allergic or have adverse reactions to any other medications not listed above?
*
Yes
No
The information provided on this medical history form is correct, to the best of my knowledge.
*
Appointment Cancellation Policy
When you schedule an appointment in our office we reserve that time specifically for you. If you need to cancel or reschedule your appointment we require 48 hours advance notice so that we can schedule another patient waiting for treatment. If you miss your appointment or do not give 48 hour notice, there may be a $150/hr charge applied to your account.
*
Office Financial Policy
Insurance
If you have dental insurance, we will make a good faith estimate of the amount your insurance carrier may pay based on the information provided to us. As the insured, it is your responsibility to determine the coverage by your insurance for any dental services provided in our office. As a courtesy, we will file all dental claims on your behalf as well as provide any information required by your insurance carrier to ensure it is processed in a timely manner. If your insurer denies coverage, or if we otherwise do not receive payment within 60 days from filling your claim, the amount will then become due and payable by you. Remember that your coverage is a contract between you and your insurer and/or your employer and your insurer. All questions regarding your insurance benefits must be addressed to your insurance carrier.
Payment
The amount estimated to be your portion of treatment, is due at the time dental treatment is provided. We accept payment in the forms of Cash/Check, Visa, Mastercard, Discover, Debit cards (that bear Visa or MasterCard logos), and Care Credit.
Patient Responsibility, Assignment and Release
I acknowledge my responsibility for the total payment of all services performed in this office in accordance with their regular fees and terms. I understand my responsibility is not modified by whether any third party (insurance) pays for all, part, or none of the charges. I understand that any estimated portion, not covered by insurance is due at the time of service for all services rendered. I understand that my account becomes delinquent if not paid within sixty (60) days after billing and that at that time a finance charge of 1.0% of the unpaid balance will be charged every month until the balance is paid in full (RCW 19.52.020). I authorize payment to be made directly to the dentist by my insurance company and I accept financial responsibility for all services not covered by my insurance. I authorize release of any medical/dental care information requested by my insurance carrier, and authorize my insurance company to pay insurance benefits directly to the dentist for all dental services rendered. We are here to assist you in any way possible. Please make your questions and concerns known to our team. Our goal is to ensure that you have an exceptional experience!
I have read and understand the Office Financial and Appointment Cancellation Policies.
*
Name of Patient
*
First
Last
Name of Legal Guardian
First
Last
STATEMENT OF PRIVACY PRACTICES
Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principal concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights.
Protecting Your Personal Healthcare Information
We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment, and our health care operations. Your personal health information will never be otherwise given to anyone – even family members – without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose. Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released.
Collecting Protected Health Information (PHI)
We will only request personal information needed to provide our standard of quality health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.
Disclosure of your Protected Health Information
We may disclose information as allowed or required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments including voicemail messages, answering machines, and postcards. You have a right to request and we will honor you written authorization to withhold disclosure to your dental insurance carrier for all services for which you have made full out-of-pocket payment. Any breach in the protection of your personal health information, including unauthorized acquisition, access, use, or disclosure, will be fully investigated, addressed, and mitigated as established by the HIPAA Privacy Rule. You have a right to and will be provided all information relating to any breach involving your personal PHI.
Your Rights as our Patient
You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services. Please ask if you have any questions about your privacy rights or the protection of your health information.
601 So. Carr Road, Suite 400 * Renton, Washington 98055 * 425-271-3500
Acknowledgement of Receipt of Statement of Privacy Practices
I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of David Ford, DDS. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility. David Ford, DDS reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.
*
Additional Disclosure Authority
In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below
Any member of my immediate family
*
Yes
No
Spouse only
*
Yes
No
Other
*
Yes
No
Name
This field is for validation purposes and should be left unchanged.
