Endo New Patient Paperwork

Salutation:

First Name:

MI:

Last Name:

Home Address:

City/ /State/Zip:

Gender:

Home Phone number:

Work Phone number:

Cell Phone number:

Birthdate:

Date

SSN:

Referred by:

Family Physician:

Family Physician phone number:

Employer name:

Employer Address:

Emergency Contact:

Patients Email:

example@example.com

Spouse:

Contact number:

Who is responsible for account?

Insurance company:

Subscribers name:

Subscribers SSN:

Subscribers DOB:

Member ID:

Group:

Relationship to Subscriber:

Do you have unhealed injuries or inflamed area, growths or sore spots in or around your mouth?

Yes No Unknown

If yes, explain:

Has there been any changes in your general health within the past year?

Yes No Unknown

If yes, explain:

Are you under the care of a physician for a current problem?

Yes No Unknown

If yes, explain:

Have you been hospitalized within the past 5 years?

Yes No Unknown

If yes, explain:

Have you received therapy for alcoholism or drug addiction during the past 5 years?

Yes No Unknown

If yes, explain:

Have you ever had any allergic or ADVERSE REACTIONS to anesthetics/antibiotics/medications?

Yes No Unknown

Please Specify:

Is there any condition concerning your health that the doctor should be told?

Yes No Unknown

Please Specify:

Do you wish to speak to the doctor about privately about anything?

Yes No Unknown

Have you had abnormal bleeding with previous extraction's surgery or trauma?

Yes No Unknown

Have you ever required a blood transfusion?

Yes No Unknown

Have you ever had radiation for any condition?

Yes No Unknown

Have you ever tested positively for HIV infection or AIDS?

Yes No Unknown

Are you required by your Doctor to take antibiotics prior to dental treatment? Due to joint replacement, heart issues, etc.....(Not for tooth issues)

Yes No Unknown

Please check each one you have or have had. *

Are you taking any herbal medicine (i.e., St.Johns Wort)?

Yes No Don't Know

Have you ever taken the "fen-phen" diet? (Example:Adipex)

Yes No Don't Know

Do you have any disease, condition or problem not listed above?

Yes No Don't Know

Specify

Are you taking bisphosphonates now or have you ever taken them in the past? (For osteoporosis)

Yes No Don't Know

Are you taking any medications or drugs? If yes, please list below and reason for taking them.

Yes No Don't Know

Please list medications or drugs and reason for taking them.

Possibility of pregnancy:

Nursing:

Estimated delivery date:

Date

Taking birth control pills:

This visit related to an accident? Yes/No

Work Related? Yes/No

Date of injury:

Date

Insurance company handling the claim:

Claim number:

Texarkana, TX 75503

Endo (903) 792-3636 Ortho (903) 793-0055 Fax (903) 792-0062

Sandra Shambarger, DDS MS-Endodontist

James Shambarger, DDS MS-Orthodontist

Privacy Practices

This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read it carefully. This information is made available upon request by a patient.

We understand that your dental health information is personal and we are committed to protecting any information about you. As our patient, we create dental records about your dental health, our care for you, and the services and/or items that we provide to you. By law, we are required to make sure that your Protected Health Information is kept private.

The following are ways in which we could use or disclose your information. All information is shared thru mail, phone or email.

· For dental treatment

· For appointment and patient recall reminders

· In response to requests arising from lawsuits or other disputes

· To avert a serious threat to health or safety

· In emergency situations

· Correspondence to your other dentist office in regards to insurance and/or payment information

· To run our practice more efficiently and ensure all patients receive quality care

If you believe that your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact the office manager. All complaints must be submitted in writing. You will not be penalized for filing a complaint.

You have certain rights regarding the information that we maintain about you. These rights include:

· The right to inspect and copy

· The right to amend

· The right to request restrictions

· The right to a paper copy of this notice

· The right to request confidential communications

Print Patients Name:

Signature:

Clear

Do you have or have you had any of the following?

Women only:

Injury