Adult New Patient Form

  • Adult New Patient Form

  • Today's Date*
     - -
  • Birth Date*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Insurance Subscriber Date of Birth
     - -

  • Dental History

  • To your knowledge do you have any outstanding dental work that needs to be completed?*
  • Do you give permission for our office to share images and consult/treatment notes with your dentist?*
  • Has there been injury to the face, head or neck?*

  • Dental History

  • History of speech problems or speech therapy?*
  • Frequent oral habits(sucking finger, chewing pen, etc.)?*
  • Tooth grinding or clenching?*
  • Clicking, locking in jaw joints?*
  • Ringing in ears, difficulty in chewing or opening jaw?*

  • Medical History

  • Do you have any of the following?*

  • Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

  • Are you under a physician’s care now?*
  • Have you ever been hospitalized or had a major operation?*
  • Are you taking any medication pills or drugs?*
  • Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphates?*
  • Do you use tobacco?*
  • Do you use controlled substances?*
  • Are you allergic to any of the following?
  • Have you ever had any serious illness not listed above?*

  • Epworth Sleep Questionnaire

    Questionnaire Used to Identify Sleep Disorder Candidates

  • Select the appropriate response:

  • Do you snore at night?*
  • Witness pauses in breathing while asleep?*
  • Do you have difficulty falling asleep?*
  • Do you have difficulty maintaining sleep?*
  • Experience a restless sensation in legs while laying awake?*
  • Kicking and twitching movements while asleep?*
  • Experience excessive daytime tiredness?*
  • Have you ever awakened feeling paralyzed?*
  • Experience a sudden loss of strength in your arms or legs?*
  • If the previous answer is Yes, were these events brought on by a sudden, frightening event or laughter?*
  • Select all that apply, do you frequently awaken with:

  • According to the following scale choose the appropriate number value to represent how likely you are to fall asleep during the day in the following situations. Try to be as honest as possible. If possible have your significant other help you fill this out.

    0 - Never        1 - Slight Chance        2 - Moderate        3 - Always

  • Sitting and reading*
  • Watching TV*
  • Sitting inactive in public (movie theater, meeting)*
  • Sitting and talking to someone*
  • As a passenger in a car for an hour without a break*
  • Driving a vehicle for two or more hours*
  • Lying down to rest in afternoon when circumstances permit*

  • Acknowledgement of Receipt of Statement of Privacy Policy

  • I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of Nelson R. Diers, D.D.S. 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.

    Nelson R. Diers, D.D.S. 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*
  • Spouse only*
  • Other (please specify)*
  • Date*
     - -

  • 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 Account-ability Act and the state of Ohio. 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 office and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentially 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

    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

    As stated above, we may disclose information as required by law. We are obligated to provide information to law enforce-ment 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 voice-mail messages, answering machines, and postcards.

    Patient Rights

    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 stat-ed 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.

    We thank you for being a patient at our office. Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.

     

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