• WELCOME TO OUR OFFICE

    Pomona Dental Practice/ Yvonne Shu DDS, Inc
  • Format: (000) 000-0000.
  • Date of birth*
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  • Sex*
  • Marital Status*

  • Emergency Contac Information

  • Format: (000) 000-0000.

  • If the patient is a minor, please answer the following

  • Date of birth
     - -
  • Format: (000) 000-0000.

  • Insurance Information

  • Do you have insurance or Medical?*
  • Date of birth
     - -

  • Dental History

  • Do your gums bleed occasionally when you brush?*
  • Are your teeth sensitive to heat or cold?*
  • Are your teeth sensitive to pressure?*
  • Are your teeth sensitive to sweets?*
  • Do you have any fear of dental work?*
  • Do you brush and floss on a routing basis?*
  • Date of last dental examination*
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  • Date of last dental cleaning*
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  • Date of last X-Rays*
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  • Date*
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  • Medical History

  • Rows
  • Do you smoke or use tobacco?*
  • Have you ever had a surgery?*
  • Were there any complication during the surgery?
  • Rows
  • Rows
  • Date*
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  • Notice of privacy practices acknowledgement

  • I understand that, under the Health Insurance Portability and Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

    • Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
    • Obtain payment from third-party payers.
    • Conduct normal healthcare operations such as quality assessments and physician certifications.

    I have received, read, and understand your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

    I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree, you are bound to abide by such restrictions.

  • Date*
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  • GENERAL DENTISTRY INFORMED CONSENT

    I understand that during my visit, it may bedetermined that one or more of the following treatments are necessary or willbe recommended to address my dental health needs. I acknowledge that thisconsent includes all potential treatments that may arise during my care.

  • Drugs and Medications:
    I understand that antibiotics, analgesics, and other medications can cause allergic reactions, such as redness, swelling, nausea, itching, vomiting, or anaphylactic shock.

    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 that were not discovered during examination. For example, root canal therapy, fillings, or crown adjustments may be necessary. I give permission for the dentist to make any/all changes deemed necessary.

    Removal of Teeth:
    I understand the risks involved in removing teeth, including pain, swelling, infection, and the possibility of injury to adjacent teeth, gums, or oral tissues. I am aware of potential complications, such as temporary or permanent numbness (paresthesia), that can result from tooth extractions.

    Crowns, Bridges, and Caps:
    I understand that it is not always possible to match the color of natural teeth with artificial ones. I also acknowledge that temporary restorations must be replaced with permanent crowns, bridges, or caps in a timely manner to avoid further complications or failure.

    Periodontal Loss (Tissue and Bone):
    I understand that I have a serious condition causing gum and bone inflammation or loss, which can lead to the loss of teeth. I have been informed about the recommended treatment plan and its importance.

    Dentures:
    I understand that wearing dentures can be challenging, particularly during initial adaptation. Immediate dentures may require adjustments and follow-up care, which may incur additional charges.

    Limitations of Dentistry:
    I understand that dentistry is not an exact science and that results cannot be guaranteed. I authorize the dentist and their team to perform the necessary dental care as outlined and understand that all fees are my responsibility.

    Dispute Resolution:
    Should any disputes arise regarding my treatment, I agree to resolve them through the Peer Review system of my local dental association.

    Acknowledgment:
    By signing below, I confirm that I have read, understood, and consent to the dental procedures as explained.

  • Date*
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