Patient Medical Information

Patient Medical Information
Name

First NameMiddle InitialLast Name
Preferred Nickname
Sex:

MaleFemale
Marital Status

MarriedSingleWidowedDivorced
Social Security
Number
Date of Birth

MonthDayYear
Date
Home Phone
Home Address
City
State
Zip
Cell No
Employer
Work No
Business Address
Occupation
Race:

WhiteBlack/ African AmericaonHispanic/ LatinoNative American/ IndianAsianOther
Spouse Information or Parent if Patient is a Minor
Name
Preferred Email
example@example.com
Birthdate

MonthDayYear
Date
Employer
Social Security No
Business Address
Business Phone
In Case of Emergency Whom Should We Notify
Phone
Dental Insurance
Name of General Dentist
Name of Medical Doctor
Whom May We Thank for Referring You
Dental Insurance
Policy No
Address
Policy Holder Name
Group No
Birthdate

MonthDayYear
Date
IfGroup Employer
Social Security No
Relationship to Patient
Secondary Dental Insurance
Group No
Address
Policy Holder Name
Birthdate

MonthDayYear
Date
Group Employer
Social Security No
Relationship to Patient
I understand that I am financially responsible for all charges whether or not paid by insurance. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all of my insurance submissions whether manual or electronic.I acknowledge the payment is due at the time of treatment, unless other arrangements are made. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor child. I accept full financial responsibility for all charges. I also authorize Emerald Coast Periodontics, P.A. to release relevant patient information (x-rays, treatment plan, and account information, etc tomy general dentist/medical doctor as well as to obtain any pertinent information needed from him/her.
DATE

MonthDayYear
Date
SIGNATURE

Clear
(name of child) do hereby request and authorize the dental staff to perform I, being the parent or guardian of necessary dental services for my child, including but not limited to x-rays and administration of anesthetics which are deemed advisable by the doctor, whether or not I am present at the actual appointment and when the treatment is rendered.
I being the parent or guardian of [name of child] do hereby request and authorize the dental staff to perform necessary dental services for my child including but not limited to xrays and administration of anesthetics which are deemed advisable by the doctor whether or not I am present at the actual appointment and when the treatment is rendered
DATE

MonthDayYear
Date
SIGNATURE

Clear
Patient Medical History
Name
Height
Weight
Age
Are you presently or this past year been under the care of a doctor?

YesNo
If yes for what reasons
Physicians name and address
Are you currently taking any drugs or medications?

YesNo
Blood Pressure Medications
Blood Thinners:

EliquisXareltoPlavixAspirin 81mg/ 325mgOther
Diabetes andor Weight LossGLP1 Medications:
Bisphosphonates:

FosmaxBonivaProliaOther
Diabetes and or Weight Loss Medication Start Date:

MonthDayYear
Date
Diabetes and or Weight Loss Medication Last Dose:

MonthDayYear
Date
Diabetes and or Weight Loss Medication Next Dose:

MonthDayYear
Date
List Other Medications/Supplements:
Are you allergic or had reactions to? (Check those that apply)

Penicillin/AmoxicillinSulfa/BactrimDoxycyclineCodeine/NarcoticsAspirinNSAIDS/Motrin/IbuprofenTylenol/AcetaminophenLatexLocal AnestheticOther
Do you have or have you had any of the following diseases or conditions? Please check all that apply.

Abnormal Blood Pressure High / LowBypass SurgeryStent PlacementHeart MurmurStrokeAtrial FibrillationSeizures/epilepsyArthritisOsteopeniaOsteoporosisDiabetes: Type 1 / Type 2AsthmaCOPD/Emphysema/ Chronic BronchitisInhalerDepression/AnxietyHepatitis A, B, CHIV/AIDSKidney DiseaseAlcoholismDrug AddictionSnoring/Sleep ApneaCancerJoint ReplacementPregnant
List ALL other diseases conditions
Do you pre-medicate with antibiotics before dental treatment?

NoYes
Do you smoke or use tobacco?

YesNo
Did you smoke in the past?

YesNo
Packs per Day
Type of Smoking

CigarsVapeSnuff/dip
When did you stop?

MonthDayYear
Date
I certify that I have read and understand the above. If I have any changes in my health, I will inform my doctor as soon as possible.
Patients Signature*

Clear
Date*

MonthDayYear
Date
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
"You May Refuse to Sign This Acknowledgement"
Signature. Please Print:
SIGNATURE

Clear
DATE

MonthDayYear
Date
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your Protected Health Information (PHI) to carry out treatment, payment activities, and healthcare operations. I am aware that some records (such as xrays and surgical photos) may be used for educational purposes, but that no identifying information will be shown according to HIPPA privacy policy.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your PHI. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your PHI that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Carol Leach, Office Manager Telephone/Fax:(850) 678-6485 Fax: (850) 678-5245 719 Bayshore Drive, Niceville, FL 32578

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the contact person listed above. Please understand that revocation of the Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent. I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my PHI to carry out treatment, payment activities and health care operations.
SIGNATURE

Clear
DATE

MonthDayYear
Date
If a personal representative on behalf of the patient signs this Consent, complete the following:
Personal Representatives Name
Relationship to Patient
YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.

(This Consent will be included in the patient's chart)

I revoke my Consent for your use and disclosure of my PHI for treatment, payment activities, and healthcare operations. I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my Consent.
Signature

Clear
Date

MonthDayYear
Date
EMERALD COAST
M. McClain Woolsey, D.D.S. 719 Bayshore Drive, Niceville, FI 32578 Phone: (850) 678-6485Fax: (850) 678- 5245
Date*

MonthDayYear
Date
Periodontics to release relevant patient information (Radiographs, Treatment Plans, and Account Information, etc to the following: (dentist, spouse, sibling, etc
Name:
Relationship:
Name:
Relationship:
Please initial here to authorize Emerald Coast Periodontics to release the same information as above to any Doctors Office that may request this information*
Please initial here to authorize Emerald Coast Periodontics to release the

same information as above, to any Doctor's Office that may request this information.
Patient or Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

Patient Medical Information

Spouse Information or Parent if Patient is a Minor

Dental Insurance

Patient Medical History

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

EMERALD COAST