Southwest Dental Group

Southwest Dental Group

Patient Registration and Medical/Dental History
So that we may provide you with the best possible care, please complete both sides of this medical/dental history form.
Date

MonthDayYear
Home Phone

Area CodePhone Number
Work Phone

Area CodePhone Number
Cell/Pager

Area CodePhone Number
E-mail
Patient Name

First NameMiddle NameLast Name
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Sex

MaleFemale
Age
Date of Birth

MonthDayYear
Marital Status

SingleMarriedWidowedSeparatedDivorced
Employed By
Occupation
Business Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Business Phone Number

Area CodePhone Number
Spouse Name

First NameLast Name
Employed By
Business Phone Number

Area CodePhone Number
Business Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Person Responsible for Account
Name

First NameLast Name
Relation
Billing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number

Area CodePhone Number
Employer
Work Phone Number

Area CodePhone Number
Ext.
Dental Insurance Primary Carrier
Insured's Name

First NameMiddle NameLast Name
Insurance Company
Telephone Number:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group #
ID #
Date of Birth

MonthDayYear
Insured's Employer
Dental Insurance Second Carrier
Insured's Name

First NameMiddle NameLast Name
Insurance Company
Telephone Number:

Area CodePhone Number
Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Group #
ID #
Date of Birth

MonthDayYear
Insured's Employer
In case of emergency who should be notified?
Phone Number

Area CodePhone Number
Whom may we thank for referring you?
MEDICAL HISTORY
Physician's Name

First NameLast Name
Date of Last Physical

MonthDayYear
Date
Phone Number

Area CodePhone Number
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
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.

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

	Yes	No
AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizsiness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pace Maker
Heart Trouble/Disease

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

	Yes	No
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung DIsease
Mitral Valve Prolapse
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatment
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsilitis
Tuberculosis
Tumors of Growths
Ulcers
Venereal Disease
Yellow Jaundice

Do you have any dental problems now?

YesNo
If yes, please describe them:

Have you ever had:

	Yes	No
Orthodontic Treatment?
Oral Surgery?
Periodontal Treatment
Your teeth ground or your bite adjusted?
A bite plate or mouth guard?

Are any of your teeth sensitive to:

	Yes	No
Hot or Cold
Sweet
Biting or Chewing

	Yes	No
Have you noticed any mouth odors or bad tastes?
Do you frequently get cold sores, blisters or any other lesions?
Do your gums bleed or hurt?
Have your parents experienced gum disease or tooth loss?
Have you noticed any loose teeth or a change in your bite?
Do you have difficulty in chewing on either side of the mouth?
Are you happy with your smile?
Are you pleased with the color of your teeth?
Would you like to keep all of your teeth all of your life?
Do you feel nervous about having dental treatment?

Are you allergic to any of the following?

AspirinPenicilinCodeineAcrylicMetalLatexLocal AnestheticsOther
Are you under a physician's care now?

YesNo
If yes, please explain:
Have you ever been hospitalized or had a major operation?

YesNo
If yes, please explain:
Have you ever had a serious head or neck injury?

YesNo
If yes, please explain:
Are you taking any medications, pills or drugs?

YesNo
If yes, please explain:
Do you take or have you taken, Phen-Fen or Redux?

YesNo
Are you on a special diet?

YesNo
Do you use tobacco?

YesNo
Do you use controlled substances?

YesNo
Women: Are You

Pregnant/Trying to get pregnant?Nursing?Type option 3Taking Oral Contraceptives
I verbally reviewed the medical/dental information above with the parent/guardian and patient named herein.
Staff/Dr.'s Initials

Clear
Date

MonthDayYear
Date
AUTHORIZATION AND RELEASE

The above information is accurate and complete to the best of my knowledge and is only for use in treatment, billing and processing of insurance for benefits for which I am entitled. I authorize the dentist to release any information, including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care, to third-party payers and/or other health practitioners.

I authorize my insurance company to pay directly to the dental office the benefits otherwise payable to me.

I understand that my dental insurance carrier may pay less than the actual bill of services. I agree to be responsible for payment of all services rendered on behalf of my dependents.
Signature of Patient or Parent of Minor

Clear
Date

MonthDayYear
Date

Southwest Dental Group
NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED ANDDISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW IT CAREFULLY.THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 4/01/03, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or other person responsible for your care, of your location, your general
condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official
lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your heath information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time.
You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $0.____ for each page, $_____ per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not
before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to an alternative location. (You must make your request in writing.) Your request must specify the alternative means or location, and provide a satisfactory explanation of how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.
QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy or your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Southwest Dental Group
1007 W. Oak Ave.
Duncan, OK 73533

Telephone: 1-580-255-6621
Fax: 1-580-252-7345

2002 American Dental Association

All Rights Reserved

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.

(This form is educational only, does not constitute legal advice, and covers only federal, not state, law in effect or proposed as of March 27, 2002. Subsequent law change may require revision.)

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I have received a copy of this office's notice of privacy practices.
Please Print Name
Signature

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Date

MonthDayYear
Date
For Office Use Only
We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because:
- INDIVIDUAL REFUSED TO SIGN
- COMMUNICATIONS BARRIERS PROHIBITED OBTAINING
- AN EMERGENCY SITUATION PREVENTED US FROM OBTAINING ACKNOWLEDGEMENT
- OTHER (PLEASE SPECIFY)
SOUTHWEST DENTAL GROUP, DR ROBERT D. SCHICK D.D.S.
1007 WEST OAK AVE
DUNCAN, OK 73533
580-255-6621

SOUTHWEST DENTAL GROUP
1007 WEST OAK AVE
DUNCAN, OK 73533
580-255-6621
WWW.BESTDUNCANDENTIST.COM
PERMISSION TO DISCUSS MEDICAL INFORMATION

All medical/dental records are confidential. We require written authorization to release medical
information to anyone other than the patient. By signing the authorization below, you are giving us permission to discuss the information contained in your medical/dental information with another individual.
I, blanks give Dr. Robert Schick and staff of Southwest Dental Group permission to discuss my diagnosis, procedures and/or treatment plan including fees with...
Please List Name(s)
Signature

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Date

MonthDayYear
Date
Printed Name

First NameLast Name

PAYMENT POLICY ACKNOWLEDGEMENT

FINANCIAL AGREEMENT
We are committed to providing you with the best possible dental care. Our fees are
representative of the usual and customary charges for our area. If you have dental insurance,
we assist you in any way we reasonably can to help get your claims paid. In order to achieve
these goals we need your assistance and your understanding of our payment policy.

It is important that you realize, however, that…

1. Your dental benefit contract is between you, your employer, and the insurance company. We are not a party to that contract. This office files your insurance as a courtesy to you, but it is not obligated to do so. Regardless, you agree to pay any services that are not covered by your insurance company. This includes, but is not limited to, coinsurance, deductibles, non-covered benefits due to policy limits or policy exclusions as well as failure to comply with your insurance plan requirements.
2. Proof of insurance. All patients must complete our patient information form. We must
obtain a copy of your current, valid insurance card and a driver’s license.
3. Insurance companies require the date of birth and social security number of the subscriber. Please make sure that information is listed on your patient history form.
4. Not all dental services are a covered benefit in all contracts.
5. You (not the insurance company) are responsible to us for all of our fees for services
rendered to you.
6. For patients who have insurance an ESTIMATE will be given of the benefits that the
insurance company is expected to pay, and any estimate is expected at the time services
are rendered.

For the convenience of our patients, we offer the following methods of payment:
- Payment in full by cash, check, bank card or alternate financing for each appointment as
  service is rendered.
- For insurance patients we will accept payment for the initial examination directly from the insurance company for that percentage the company will cover. We gladly accept insurance assignments, but require that the deductible and non- covered fees be paid at each visit. In the event of a duplicate payment, you will be reimbursed or your account credited.
- Bank charge cards - Visa, Discover & MasterCard are accepted.
- Alternate financing (CareCredit) accounts are gladly accepted. We will be glad to assist
  you in filling out an application. Credit approval is required.
- Major services: Appliances, crowns, bridge partials and dentures. Payment of ½ at the
  initial appointment and the balance must be paid in full upon delivery.
Southwest Dental Group, Robert D. Schick, D.D.S.
1007 West Oak Ave, Duncan, OK 73533
580-255-6621

Non-Payment
If your account is 90 days past due, you will receive a letter stating you have 10 days to pay
your account in full. Partial payments will not be accepted unless otherwise negotiated. Please
be aware if a balance remains unpaid, we may refer your account to a collection agency and/or
report to the credit bureau. You and your immediate family member may be discharged from
this practice. If this is to occur, you will be notified by mail that you have 30 days to find
alternate dental care. During that 30 day period, our dentist will only be able to treat you on an emergency basis.

*Please be aware that any parent bringing a child to our office is legally responsible for
payment of ALL services rendered.

Missed Appointments

**Please give 24 hours notice of cancellation or charges may be your responsibility.**

We will gladly discuss your proposed dental treatment and answer any questions you might
have as to the involvement of your dental benefit program in receiving this care. We
appreciate the opportunity to serve you.
I, the undersigned, as the patient or legal agent of the patient, hereby certify that I have read, and fully and completely understand the payment policy acknowledgment for dental treatment and that I have signed the payment policy acknowledgment knowingly, freely, voluntarily, and agree to be bound by its terms.
Patient/Authorized Representative Signature:

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Date

MonthDayYear
Date
Relationship to Patient
Witness Signature and Title:

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Additional Witness Signature and Title: (Patient was unable to sign or refused to sign)

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Should be Empty:

Southwest Dental Group

NOTICE OF PRIVACY PRACTICES

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

PAYMENT POLICY ACKNOWLEDGEMENT

Non-Payment