Patient Reg Form

COVID-19 QUESTIONNAIRE

Patient Disclosures
This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19 virus.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

Rows	Yes	No
Do you have a fever or above normal temperature?
Have you experienced shortness of breath or had trouble breathing?
Do you have a dry cough?
Do you have a runny nose?
Have you recently lost or had a reduction in your sense of smell?
Do you have a sore throat?
Have you been in contact with someone who has tested positive for COVID-19?
Have you tested positive for COVID-19?
Have you been tested for COVID-19 and are awaiting results?
Have you traveled outside the United States by air or cruise ship in the past 14 days?
Have you traveled within the United States by air, bus or train within the past 14 days?

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Signature of patient (Parent or Guardian if Minor)

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Witness
Date

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COVID-19 PANDEMIC DENTAL TREATMENT NOTICE AND ACKNOWLEDGMENT OF RISK FORM
The World Health Organization has characterized the COVID-19 virus, also known as "Coronavirus," as a pandemic. Our practice wants to ensure you are aware of the risks of exposure to COVID-19 associated with receiving treatment during this pandemic.

COVID-19 is highly contagious and has a long incubation period. You or your healthcare providers may have the virus, not show symptoms and yet still be highly contagious. COVID-19 can result in a life-threatening respiratory disease in some patients. You may be exposed to COVID-19 at any time or in any place. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

Dental procedures can create fine water spray or "aerosols" which may remain in the air for several minutes to hours. These aerosols may contain the COVID-19 virus and may create a risk of COVID-19 exposure. You cannot wear a protective mask over your mouth to reduce exposure during treatment as your healthcare providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.

To provide a safe environment for our patients and staff, this practice follows the applicable state and federal regulations and protocols for infection control, universal personal protection, and disinfection. However, due to the nature of the procedures we provide, it may not be possible to maintain social distancing between patients, doctors, and staff at all times.

Patient Acknowledgement

I acknowledge that I have read the Notice above and that I understand and accept that there is an increased risk of COVID-19 exposure with treatment during the pandemic.

I understand and accept the increased risk of COVID-19 exposure with treatment at this office.

I also acknowledge that I could, or may have, exposure to COVID-19 from outside this office and unrelated to my visit here.
Signature of patient (Parent or Guardian if Minor)

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Doctor
Date

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PATIENT INFORMATION
Today's Date

MonthDayYear
Mr.Mrs.Ms.Dr.
MaleFemale
First Name
MI
Last Name
Birth Date

MonthDayYear
Age
Soc. Sec. #
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Referred By

First NameLast Name

Rows	Yes	No
Have you ever been a patient of our practice?
Has a family member ever been a patient of our practice?

Medical Doctor

First NameLast Name
Preferred Pharmacy
Tel.

Area CodePhone Number
Driver's License #
Nearest relative not living with you

First NameLast Name
Tel.

Area CodePhone Number
Employer
Business Tel.

Area CodePhone Number
CashCheckCredit Card
In case of emergency, please contact
Tel.

Area CodePhone Number
Relation
Who Will Be Responsible For Your Account
Self (If self, skip this section)SpouseFatherMotherOther
Name

First NameLast Name
Soc. Sec. #
Birth Date

MonthDayYear
Age
Home Phone

Area CodePhone Number
Cell Phone

Area CodePhone Number
Email
example@example.com
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Driver's License #
Employer
Business Tel.

Area CodePhone Number
SPOUSE OR OTHER GUARANTOR INFORMATION (IF DIFFERENT FROM ABOVE)
Name

First NameLast Name
Relation
Soc. Sec. #
Birth Date

MonthDayYear
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tel:

Area CodePhone Number
Employer
Business Tel.

Area CodePhone Number
Insurance Information
Full TimePart TimeNot
School Name
School Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
MarriedDivorcedWidowSingleLegally Separated
Full TimePart TimeRetiredNotLegally Separated
PPOHMO
Primary Dental Insurance Company
Employer
Business Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Tel.

Area CodePhone Number
Plan
Insurance Co. Name
ID #
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tel.

Area CodePhone Number
Group Name
Group #
Insured Party

First NameLast Name
Relation
Birth Date

MonthDayYear
MF
Soc. Sec. #
Tel.

Area CodePhone Number
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Secondary Dental Insurance Company
Employer
Business Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Business Tel.

Area CodePhone Number
Plan
Insurance Co. Name
ID #
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Tel.

Area CodePhone Number
Group Name
Group #
Insured Party

First NameLast Name
Relation
Birth Date

MonthDayYear
MF
Soc. Sec. #
Tel.

Area CodePhone Number
Address

Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Health History
To our patients:

Although dentists primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have, or medications that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.
Reason for today's office visit?
1. Height
Weight
YesNo
YesNo
YesNo
Date of last visit

MonthDayYear
If so, for what are you being treated?
YesNo
If so, describe
YesNo
If so, describe where
YesNo
If so, describe where
YesNo
YesNo

Have you had, or do you currently have:

Rows	Yes	No
9. Rheumatic fever?
10. Damaged heart valves / mitral valve prolapse?
11. Heart murmur?
12. High blood pressure?
13. Low blood pressure?
14. Chest pain / angina?
15. Heart attack(s)?
16. Irregular heart beat?
17. Cardiac pacemaker?
18. Heart surgery?
19. Pneumonia, bronchitis, chronic cough?
20. Asthma?
21. Hay fever / sinus problems?
22. Snoring?
23. Sleep apnea / CPAP?
24. Difficult breathing / other lung trouble?
25. Tuberculosis?
26. Emphysema?
27. Do you smoke or vape?
28. Do you use chewing tobacco?
29. Blood transfusion?
30. Blood disorder such as anemia?
31. Bruise easily?
32. Bleeding tendency / abnormal bleed?
33. Hepatitis, jaundice, or liver disease?
34. Infectious mononucleosis?
35. Gallbladder trouble?

Have you had, or do you currently have:

Rows	Yes	No
36. Fainting spells?
37. Convulsions / epilepsy?
38. Stroke?
39. Thyroid trouble?
40. Diabetes?
41. Low blood sugar?
42. Kidney trouble?
43. High cholesterol?
44. Are you on dialysis?
45. Swollen ankles / arthritis / joint disease?
46. Osteoporosis / osteopenia?
47. Osteonecrosis?
48. Stomach ulcer / acid reflux?
49. Contagious diseases?
50. Sexually transmitted diseases?
51. Problems with immune system? Possibly from medication / surgery, etc.
52. Delay in healing?
53. A tumor or growth?
54. Cancer / radiation therapy / chemotherapy?
55. Chronic fatigue / night sweats?
56. Are you on a diet?
57. A history of alcohol abuse?
58. A history of marijuana or other drug use?
59. Contact lenses?
60. Eye disease / glaucoma?
61. Mental health problems / anxiety / depression?
62. A removable dental appliance?
63. Pain or clicking of jaws when eating?

Women Only

(QUESTIONS 64-67)
YesNo
65. Expected delivery date?

MonthDayYear
YesNo
YesNo
Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other methods of birth control.

ARE YOU NOW TAKING:

Rows	Yes	No
68. Any kind of medication, drug, pills?
69. Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Xarelto, Eliquis, Fish oil)?
70. Have you ever taken diet pills?
71. Any natural product, herbal supplement or homeopathic remedy?
72. Are you taking, or have you ever taken bone density meds, RANKL inhibitors or bisphosphonates such as Prolia, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, Xgeva, or Evista in the past 12 years?

73. Tranquilizers, sleeping pills, anti-depressants, and/or narcotics on a regular basis? If so, please list:
MethadoneSuboxoneOxycodoneFentanylOther
Treating doctor:
75. Please list any medications you are currently taking:
YesNo
If Yes, describe
YesNo

ARE YOU ALLERGIC TO, OR HAD A REACTION TO:

Rows	Yes	No
76. Local anesthetic (numbing meds.)?
77. Penicillin?
78. Other antibiotics?
79. Sulfa Drugs?
80. Sodium pentothal / Valium /other tranquilizers?
81. Aspirin?
82. Amoxicillin?
83. Codeine or other narcotics?
84. Latex?
85. Sulfites?
86. Do you have any known allergies?

86. Please list any allergies other than drug allergies:
86. Please list any other medication or antibiotic you are allergic to:
CancerDiabetesHeart diseaseAnesthesia problems
YesNo
AutomobileWork relatedOther
Date of injury

MonthDayYear
Insurance company handling the claim
Claim number
Name of attorney / adjustor
Telephone number

Area CodePhone Number
I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.
Signature of patient (Parent or Guardian if Minor)

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Date

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Reviewed by
Date

MonthDayYear
FEES & PAYMENTS
We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance, we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.
Signature of patient (Parent or Guardian if Minor)

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Date

MonthDayYear
This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.
Signature of patient (Parent or Guardian if Minor)

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Date

MonthDayYear
AUTHORIZATION
I authorize my dentist and his / her designated staff, to perform an oral examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages to be left on my phone and / or mobile phone concerning my appointment
I permit the office to communicate with me via text message on my cell phone.
Signature of patient (Parent or Guardian if Minor)

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Doctor
Date

MonthDayYear
I have read the Dental Materials Fact Sheet provided at this link: https://www.dbc.ca.gov/formspubs/pub_dmfs_english_webview.pdf
Signature

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Date

MonthDayYear
I hereby acknowledge that a copy of this office's Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may has e regarding this Notice.

HIPAA-Notice-of-Privacy-Practices-highlighted-changes
Signature of patient (Parent or Guardian if Minor)

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Date

MonthDayYear
Patient Questionnaire
Patient Name
1. When was your last visit to a dental office?
What was done at that time?
2. Is there a particular reason why you have not returned to your previous office?
3. Dentally, what concerns you the most?
YesNo
If so, where?
For how long?
YesNo
If so, where?
For how long?
YesNo
If so, where?
For how long?
YesNo
If so, when and where?
YesNo
If so, where?
For how long?
YesNo
If so, when and with whom?
YesNo
YesNo
Was it helpful?
YesNo
YesNo
If so, please describe
YesNo
If so, please describe
ExtremelyModeratelySlightlyNot
YesNo
YesNo
If so, how and why are they missing?
YesNo
YesNo
If so, where?
YesNo
YesNo
YesNo
YesNo
If so, where?
YesNo
If so, where?
YesNo
YesNo
YesNo
If no, please explain
28. What, if anything, were you told about our office that appealed to you?
29. Do you have any particular interest, hobbies or sports?
Please verify that you are human*
By providing my phone number, I consent to receive SMS text messages from [Perry Woo, DDS] for appointment reminders, marketing messages, and general two-way communication. Msg frequency varies. Msg&data rates may apply. Reply HELP for support. Reply STOP to opt out. Terms and Conditions / Privacy Policy
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COVID-19 QUESTIONNAIRE

COVID-19 PANDEMIC DENTAL TREATMENT NOTICE AND ACKNOWLEDGMENT OF RISK FORM

PATIENT INFORMATION

Who Will Be Responsible For Your Account

SPOUSE OR OTHER GUARANTOR INFORMATION (IF DIFFERENT FROM ABOVE)

Insurance Information

Primary Dental Insurance Company

Secondary Dental Insurance Company

Health History

Women Only

FEES & PAYMENTS

AUTHORIZATION

Patient Questionnaire