English & Spanish - Patient Registration and Medical History

Patient Registration and Medical History
Today's Date:*

MonthDayYear
Name:*

First NameLast Name
Birthdate:*

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Age:*
Address:*

Street Address

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CityState / Province

Postal / Zip Code
Home Phone Number:
Please enter a valid phone number.
Cell Phone Number:
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Social Security Number:
Are you married?*

YesNo
Spouse's Name:

First NameLast Name
Employer (Self):*
Business Phone Number:
Please enter a valid phone number.
Employer (Spouse):
Business Phone Number:
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If minor, parent or guardians name:

First NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Phone Number:
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Insurance Information
Policy Holders Name:

First NameLast Name
Employer:
Policy Number:
Date of Birth:

MonthDayYear
Social Security Number:
Dental Health Questionnaire
Do you have any allergies?*

YesNo
If yes, please list:
Previous Dentist:*

First NameLast Name
Date of last visit:

MonthDayYear
Are you presently ill or under the care of a physician?*

YesNo
If yes, please describe:
History of hospitalizations:
Do you require pre-medication prior to dental work?*

YesNo
Please list all medications you are currently taking (including aspirin, etc.)
Do you use tobacco products?*

YesNo
If yes, what type list:
Females
Are you taking birth control pills?*

YesNo
Are you or might be pregnant?*

YesNo
If yes, what is your estimated delivery?

MonthDayYear
Date
Whom may we thank for referring you?

First NameLast Name
Medical History

Have you ever had any of the following?*

	Yes	No
Allergies
Arthritis
Artificial Heart Valves or Joints, Screws, etc.
Back Problems
Blood Disease
Cancer
Chemical Dependency
Chronic Diarrhea
Circulatory Problems
Congenital Heart Lesions
Diabetes
Epilepsy
Headaches
Heart Murmur
Heart Problems
Hemophilia
Hepatitis, Jaundice or Liver Disease
Hernia Repair
High Blood Pressure
HIV / AIDS
Low Blood Pressure
Mitral Valve Prolapse
Nervous Problems
Pacemaker
Psychiatric Care
Radiation Treatment
Recent Weight Loss
Respiratory Disease
Rheumatic Fever
Sinus Problems
Special Diet
Stroke
Swollen Neck Glands
Ulcer
Venereal Disease

Are you or have you taken Bisphoshonate (Reclast, Actonel, Fosamax, Boniva, Aredia)?

YesNo
Are you taking any medication for Osteoporosis?

YesNo
Do you have any drug allergies or have you ever had an adverse reaction to any medication or anesthesia?*

YesNo
If so, what?
Have you ever responded adversely to medical or dental treatment?*

YesNo
Are you using any recreational drugs? (marijuana, cocaine, etc.)*

YesNo
Are you under the care of a physician?*

YesNo
If yes, what condition(s)?
Do you have any disease, condition or problem not listed above. If yes, please describe:
First Name Last Name , Area Code Phone Number Hereby acknowledges that I have received a copy of this practice's NOTICE OF PRIVACY PRACTICES. I further understand that the practice will offer me updates to this NOTICE OF PRIVACY PRACTICES should is be amended, modified, or changed in any way.
I have received a copy of the DENTAL MATERIALS FACT SHEET as required by law.*

Yes
To the best of my knowledge, all of the preceding answers are true and correct. If I have a change in my health or if my medications change, I will inform the doctor at my next appointment.
Patient Signature (use your mouse to sign in box below):*

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Date:*

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Physician Patient Arbitration Agreement
Article 1 – Agreement to Arbitrate: It is understood that any dispute as to medical malpractice, that is as to whether any medical services rendered under this contract were unnecessary or unauthorized or were improperly, negligently, or incompetently rendered, will be determined by submission to arbitration as provided by California Law, and not by a lawsuit or resort to court process except as California Law provides for judicial review or arbitration proceedings. Both parties to this contract, by entering into it, are giving up their constitutional rights to have any such dispute decided in a court of law before a jury, and instead are accepting the use of arbitration.
Article 2 – All claims Must be Arbitrated: It is the intention of the parties that this agreement bind all parties whose claims may arise out of or relate to treatment or service provided by the physician including any spouse or heirs of the patient and any children, whether born or unborn, at the time of the occurrence giving rise to any claim. In the case of any pregnant mother, the term “patient” herein shall mean both the mother and the mother’s expected child or children.
All claims for monetary damages exceeding the jurisdictional limit of the small claims court against the physician, and the physician’s partners, associates, association, corporation or partnership, and the employees, agents and estates of any of them, must be arbitrated including, without limitation, claims for loss of consortium, wrongful death, emotional distress or punitive damages, Filing of any action in any court by the physician to collect any fee from the patient shall not waive the right to compel arbitration of any malpractice claim.
Article 3 - Procedures and Applicable law: A demand for arbitration must be communicated in writing to all parties. Each party shall select an arbitrator (party arbitrator) within thirty days and a third arbitrator (neutral arbitrator) shall be selected by the arbitrators appointed by the parties within thirty days of demand for a neutral arbitrator by either party. Each party to the arbitration shall pay such party’s pro rata share of the expenses and fees of the neutral arbitration, together with other expenses of the arbitration incurred or approved by the neutral arbitrator, not including counsel fees or witness fees, or other expenses incurred by a party for such party’s own benefit. The parties agree that the arbitrators have the immunity of judicial officer from civil liability when acting in the capacity of arbitrator under this contract. This immunity shall supplement, not supplant any other applicable statutory or common law. Either party shall have the absolute right to arbitrate separately the issue of liability and damages upon written request to the neutral arbitrator.
The parties consent to the intervention and joinder in this arbitration of any person or entity which would otherwise be a proper additional party in a court action, and upon such intervention and joinder any existing court action against such additional person or entity shall be stayed pending arbitration.
The parties agree that provisions of California Law applicable to healthcare providers shall apply to disputes with this arbitration agreement, including, but not limited to, Code of Civil Procedure Section 340.5 and 667.7 and Civil Code Sections 3333.1 and 3333.2. Any party may bring before the arbitrators a motion for summary judgment or summary adjudication in accordance with the Code of Civil Procedure. Discovery shall be conducted pursuant to Code of Civil Procedure Section 1283.05, however, depositions may be taken without prior approval of the neutral arbitrator.
Article 4 – General Provisions: All claims based upon the same incident, transaction or related circumstances shall be arbitrated in one proceeding. A claim shall be waived and forever barred if (1) on the date notice thereof is received, the claim, if asserted in a civil action, would be barred by the applicable California Statute of limitations, or (2) the claimant fails to pursue the arbitration claim in accordance with the procedures prescribed herein with reasonable diligence. With respect to any matter not herein expressly provided for, the arbitrators shall be governed by the California Code of Civil Procedure provisions relating to arbitration.
Article 5 – Revocation: This agreement may be revoked by written notice delivered to the physician within 30 days of signature. It is the intent of this agreement to apply to all medical services rendered anytime for any condition.
Article 6 – Retroactive Effect: If patient intends this agreement to cover services rendered before the date it is signed (including, but not limited to, emergency treatment) patient should initial below:
Patient's or Patient's Representative's Initials:*

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If any provision of this arbitration agreement is held invalid or unenforceable, the remaining provisions shall remain in full force and shall not be affected by the invalidity of any other provision. I understand that I have the right to receive a copy of this arbitration agreement. By my signature below, I acknowledge that I have received a copy.
NOTICE: BY SIGNING THIS CONTRACT YOU ARE AGREEING TO HAVE ANY ISSUE OF MEDICAL MALPRACTICE DECIDED BY NEUTRAL ARBITRATION AND YOU ARE GIVING UP YOUR RIGHT TO A JURY OR COURT TRIAL. SEE ARTICLE 1 OF THIS CONTRACT.
Patient or Patient Representative's Signature:*

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Patient's Name:*

First NameLast Name
Date*

MonthDayYear
OFFICE USE ONLY
Physician or Authorized Representative's Signature

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Type Name:

First NameLast Name

Patient Consent to Treatment
Patient Name:*

First NameLast Name
1. DRUGS, MEDICATIONS, AND ANESTHESIA:
I understand that antibiotics, analgesics, and other medications may cause adverse reactions, some of which are, but are not limited to, redness and swelling of tissues, pain, itching, vomiting, dizziness, miscarriage, cardiac arrest. I understand that medications, drugs, and anesthetics may cause drowsiness and lack of coordination, which can be increased using alcohol or other drugs. I have been advised not to consume alcohol, not operate any vehicle or hazardous device while taking medications and/or drugs, or until fully recovered from their effects (this includes a period of at least twenty-four (24) hours after my release from surgery).
I understand that occasionally, upon injection of a local anesthetic, I may have prolonged, persistent anesthesia, numbness, and/or irritation to the area of injection.
I understand that if I select to utilize Nitrous Oxide, “Atarax” Chloral hydrate, “Xanax”, or any other sedative, possible risks include, but are not limited to, loss of consciousness, obstruction of airway, anaphylactic shock, and cardiac arrest.
I understand that someone needs to drive me home from the dental office after I have received sedation. I also understand that someone needs to watch me closely for a period of 8 to 10 hours, following my dental appointment, to observe for possible deleterious side effects, such as obstruction of airway.
Initials (Use mouse to initial in box below):*
2. CHANGES IN TREATMENT PLAN:
I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth and oral soft / hard tissue that were not discovered during examination (for example, root canal therapy following routine a specialist, medical doctor, or other healthcare professional, and the costs occurring as the consequence of this referral or any changes in the treatment plan will be my responsibility.
Initials (Use mouse to initial in box below):*
3. HYGIENE AND PERIODONTICS (TISSUE AND BONE LOSS):
I understand that the long-term success of treatment and status of my oral condition depends on my efforts at proper oral hygiene (i.e., brushing and flossing) and maintaining regular recall visits.

PERIODONTICS – I understand that I have a serious condition, causing gum and bone inflammation and/or loss, and that it can lead to loss of my teeth and other complications. The various treatment plans have been explained to me, including gum surgery, replacement and/or extractions. I also understand that although these treatments have a high degree of success, they cannot be guaranteed. Occasionally, treated teeth may require extraction. I have been given the option to be referred to a specialist as well.
Initials (Use mouse to initial in box below):*
4. REMOVAL OF TEETH:
I understand that the purpose of the procedure/surgery is to treat and possibly correct my diseased oral tissues. The doctor has advised me that if this condition persists without treatment or surgery, my present oral condition will probably worsen in time. Potential risks include, but are not limited to the following:

A. Post-operative discomfort; swelling; prolonged bleeding; tooth sensitivity to hot or cold; gum shrinkage (possibly exposing crown margins); tooth looseness; delayed healing (dry-socket) and/or infections (requiring prescriptions or additional treatment, i.e. surgery).
B. Injury to adjacent teeth, caps, or fillings (requiring the recementation of fillings, fabrication of crowns, replacement of fillings, fabrication of crowns or extraction), or injury to other tissues not within the described surgical area.
C. Limitation of opening; stiffness of facial and/or neck muscles; change in bite; or temporomandibular joint (jaw Residual joint) difficulty (possibly requiring physical therapy or surgery).
D. Residual root fragments or bone spicules left when complete removal would require extensive surgery or needless surgical complications.
E. Possible bone fracture, which may require wiring or surgical treatment.
F. Opening of the sinus (a normal cavity situated above the upper teeth) requires additional surgery.
G. Injury to the nerve underlying the teeth resulting in itching, numbness, or burning of the lip, chin, gums, cheek, teeth and/or tongue on the operated side; this may persist for several weeks, months, or in remote instances, permanently.

I give my consent for the doctor to perform the treatment/procedure/surgery previously explained to me, or other procedures deemed necessary or advisable as necessary to complete the planned operation.
If any unforeseen condition should arise during the operation, calling for the doctor’s judgment or for procedures in addition to or different from those now contemplated, I request and authorize the doctor to do whatever he may deem advisable, including referral to another dentist or specialist. I also understand that the cost of this referral would be my responsibility.
Initials (Use mouse to initial in box below):*
5. FILLINGS: I have been advised of the need for fillings, either the silver or composite (tooth color), to replace tooth structure lost to decay. I understand that with time, fillings will need to be replaced due to wearing of material. In cases where very little tooth structure remains, or existing tooth structure fractures off, I may need to receive more extensive treatment (such as root canal therapy, post, buildup and crowns), which would necessitate a separate charge.

I understand that the silver amalgam restoration is an acceptable procedure according to the American Dental Association guidelines, although, the advantages and disadvantages have been explained to me as well as alternative materials.
Initials (Use mouse to initial in box below):*
6. ENDODONTIC TREATMENT (ROOT CANAL THERAPY):
The purpose and method of root canal therapy have been explained to me, as well as reasonable alternative treatments and the consequences of non-treatment. I understand that following root canal therapy my tooth will be brittle and must be protected against fracture by replacement of a crown (cap) over the tooth. I understand that treatment risks can include, but are not limited to the following:

A. Post treatment discomfort lasting a few hours to several days for which medication will be prescribed if deemed necessary by the doctor.
B. Post treatment swelling or the gum area in the vicinity of the treated tooth or facial swelling, either of which may persist for several days or longer.
C. Infection.
D. Restricted jaw opening.
E. Breakage of root canal instruments during treatment, which may in the judgment of the doctor, be left in the treated root canal or bone as part of the filling material or it may require surgery for removal.
F. Perforation of the root canal with instruments, which may require additional surgical treatment or result in premature tooth loss or extraction.
G. Risk of temporary or permanent numbness in treat area.

If an “open and mediate” or pulpotomy procedure is performed, I understand that this is not permanent treatment and I need to pay for and finish final root canal therapy. If root canal treatment is not finalized, I expose myself to infection and/or tooth loss. If failure of root canal therapy occurs, the treatment may have to be redone, root-end surgery may be required, or the tooth may have to be extracted. I understand that I may end of extracting the tooth, in such a case I will be responsible for all the costs of the Root Canal, Post and Crown.
Initials (Use mouse to initial in box below):*
7. CROWN AND BRIDGE (CAPS):
I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I understand that at times, during the preparation of a tooth for a crown, pulp exposure may occur, necessitating possible root canal therapy.
I understand that like natural teeth, crowns and bridges need to be kept clean with proper oral hygiene and periodic cleanings, otherwise decay may develop underneath and/or around the margins of the restoration, leading to further dental treatment.
Crown and Bridge will be ready in 2 weeks. You need to come back for the delivery of it. If the temporary broke or de-cemented, you must come to recement it. If you don’t come back your teeth will be shifted, and the crown or bridge won’t fit. We would need to remake it again and you will be charged $200 per unit.
Initials (Use mouse to initial in box below):*
8. DENTURES – COMPLETE OR PARTIAL:
The problems of wearing dentures have been explained to me including looseness, soreness, and possible breakage, and relining due to tissue change. Follow-up appointments are an integral part of maintenance and success of a prosthetic appliance. The doctor should immediately examine persistent sore spots.
I further understand that surgical intervention (i.e., tori [bone] removal, bone recontouring, or implants) may be needed for dentures to be properly fitted. I also understand that due to bone loss or other complicated factors, I may never be able to wear dentures to my satisfaction.
Initials (Use mouse to initial in box below):*
9. PERIODONTICS (CHILDREN'S DENTISTRY):
I understand that the following procedures are routinely used at DENTAL AND IMPLANT CARE CENTER, as well as being accepted procedures in the dental profession.

POSITIVE REINFORCEMENT – Rewarding the child who portrays desirable behavior by use of compliments, praise, a pat or hug, and/or token objects or toys.

VOICE CONTROL – changing the tone or increasing the volume of the doctor’s voice gains the attention of a disruptive child.

NITROUS OXIDE AND/OR ORAL SEDATION – Nitrous Oxide is a mild gas that is mixed with oxygen and is used to sedate a person. It is administered through a mask placed over the child’s nose. Oral sedations are medications administered to children to help them relax. With their use the parent or guardian must understand that the child should not eat or drink for a period of four hours prior to the sedation appointment. The parent or guardian must be available to escort the child home after the sedation procedure and observe their behavior throughout the day.

I understand that with the use of an injection, used to numb the tooth area for dental procedures, the possibility exists that the child may inadvertently bite their lip causing injury to occur.
I understand the need to return to the office for evaluation if swelling and/or pain in my child does not go away after a sufficient period of time.
Initials (Use mouse to initial in box below):*
10. SEDATION:
I have been informed of minor risks including but no limited to nausea, vomiting, ineffective sedation, excitement, delay recovery, incoordination, over sedation and major risks including but not limited to allergic reaction, and respiratory depression. I hereby consent to the administration thereof; No Warranty or Guarantee has been made to the result of the thereof. I understand that I will be responsible for the costs thereof.
Initials (Use mouse to initial in box below):*
I UNDERSTAND THAT NO GUARANTEE OR ASSURANCE HAS BEEN GIVEN THAT THE PROPOSED TREATMENT WILL BE CURATIVE AND/OR SUCCESSFUL TO MY COMPLETE SATISFACTION. I AGREE TO COOPERATE COMPLETELY WITH THE RECOMMENDATIONS OF THE DOCTOR WHILE I AM UNDER HIS/HER CARE, REALIZING THAT ANY LACK OF THE SAME COULD RESULT IN LESS THAN OPTIMUM RESULTS.

I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS AND WORDS WITHIN THE ABOVE, INCLUDING THE OPPOSING SIDE OF THIS DOCUMENT, AND CONSENT TO QUESTIONS AND HAVE THEM ANSWERED TO MY SATISFACTION.

I UNDERSTAND THAT DENTAL AND IMPLANT CARE CENTER PROVIDES DENTAL CARE SERVICES WITHOUT DISCRIMINATION BASED ON RACE, RELIGION, COLOR, NATIONAL ORIGIN, SEX, SEXUAL ORIENTATION, PHYSICAL OR MENTAL ABILITY, AGE, OR MARITAL STATUS OF EACH OF ITS PATIENTS.
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Patient Registration and Medical History

Insurance Information

Dental Health Questionnaire

Females

Medical History

Physician Patient Arbitration Agreement

Patient Consent to Treatment