• Medical and Dental History Intake Form

    Please complete all sections accurately. Your responses are confidential and will be mapped to your official patient record.

  • Patient Information

  • Format: (000) 000-0000.

  • Preferred Pharmacy

  • Format: (000) 000-0000.

  • Quick Reference Section

  • Have you been under the care of a medical doctor during the past two years?*
  • Are you taking or have you ever taken any of the following medications? (Fosamax, Actonel, Boniva, Prolia, Aredia, Reclast, Zometa, Xgeva)*
  • Are you taking any weight loss medication? (Semaglutide, Mounjaro, Ozempic, Rybelsus, Wegovy, Phenteramine, or any others?)*
  • Do you or have you used any illegal substances?*
  • Do you use any marijuana or cannabis products?*
  • Do you smoke tobacco?*
  • If Yes, Date started using (mm/dd/yyyy):
     - -

  • Medical Background

  • Date of Birth (mm/dd/yyyy)*
     - -
  • Gender*
  • Date of last physical exam
     - -
  • Format: (000) 000-0000.
  • Are you in good general health?*
  • Have there been any changes to your general health in the past year?*
  • Have you had any serious illness or operation within the last 5 years?*
  • Have you ever had any excessive bleeding requiring special treatment?*

  • Women’s Health

  • Are you pregnant/trying to get pregnant/breastfeeding?
  • Do you have any problems with your menstrual period?
  • Are you undergoing any hormonal therapies?
  • Are you taking oral contraceptives?

  • Allergies

  • Medical History

  • Last Dental Visit

  • Last Dental Visit
     - -
  • Have you been to the dentist before?*
  • Approximate Date of Last X-Rays
     - -

  • Dental History

  • Are you having tooth or gum pain at this time?*
  • Do you feel nervous about having dental treatment?*
  • Have you ever had a bad experience in a dental office?*
  • Are you satisfied with the appearance of your teeth?*
  • Do you have headaches, earaches or neck pain?*
  • Do you frequently experience sinus problems?*

  • Facial/Jaw Pain

  • Orthodontic

  • Have you ever had orthodontic treatment?*

  • Sleep/Airway Issues

  • Do you have any sleep/airway issues?*
  • Does the patient tend to be a mouth breather?*
  • Does the patient snore at night?*
  • Does the patient seem rested in the morning?*
  • Is the patient often sleepy during the day?*
  • Has the patient seen an ear, nose or throat specialist?*
  • CPAP?*
  • Prior TMJ treatment?*
  • Is the patient using a sleep apnea device?*

  • Consent for Treatment

  • Consent for Treatment - Date*
     - -

  • Notice of Privacy Practices

    This notice is to inform you that your personal health information will only be used for purposes of treatment in our facility and will not be misued or disclosed by/to anyone outside of our practice. You may gain access to this information if you desire. 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 on April 14, 2003 and will remain in effect. We reserve the right to change our privacy practices and the terms of this 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 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.

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

    Payment: We may use and disclose your health information to obtain payment for services we provide (i.e: insurance companies)

    Healthcare Operations: We may use and disclose your health information to obtain in connections 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, licensing or credentialing activities.

    Your Authorization

    You may give us written authorizations to use your health information or to disclose it to anyone for any purpose (e.g. a family member picking up records, referral to dental specialists, etc.) IF you give us authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosure permitted by your authorization while it was in effect. Unless you give a writtenm authorization, we cannot disclose 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 Patients 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 we may do so.

    Persons Involved In Care

    We May use or disclose health information to notify or assist in the notification of (included indentifying or locating) a family member, your personal representative or another 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 of disclosures. In the event of your incapacity, or emergency circumstances, we will disclose health information based on a determination using our professional judgement disclosing only health information that is directly relevant to that persons involvement with your healthcare. We will also use our professional judgement and our experience with common practice to make reasonale 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 Relation Services: Our dental office does not use patient information for any marketing purposes. We will not use your health information for marketing communications without your witten authorization. 

    Required by law: We may use or disclose your health information when it is required by law to do so. (I.E Missing persons, etc)

    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, 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 authoritiesthe health information of Armed Forces personel under certain circumstances. We may disclose to lawfully authorize federal officials health informations required by lawful intelligence, counterintelligience, and other national security acitivities.  We may disclose to correctional institutions or law enforcement officials having 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 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 your request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may obtain a form to request access to your health information. We may charge you a reasonable cost based fee for expenses such as copies and staff time. You may request access by sending us a letter to the address at the end of this notice. 

    Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for any purpose, other than treatment, payment, healthcare operations, and certain other acitvities, 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.

    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 restrcitions, 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 alternative locations. You must make this request in writing. Your request must specify the alternative means/locations and provide satisfactory explanation 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. It must explain why the information should be amended. We may deny your request under certain circumstances. 

    Questions and Complaints: 

    If you desire further information about our privacy practices or if you have questions, please contact us. If you are ocncerned that 1) we may have violated your privacy right, 2) you disagree with a decision we made about access to your health information, 3) in response to a request you made to amend or restrict to use or disclosure of your health information or 4) 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 complaint to the U.S Department of Health and Human Services. We will provide you with the address to file your complaint upon request.

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

    Contact Officer: Chris Wards DDS, Privacy Officer, Owner

    Telephone: (918) 906-2525

    Address: 5522 S Lewis Ave, Tulsa, Oklahoma

     

     

     

  • HIPAA Consent - I have been offered and/or received a copy of the currently effective Notice of Privacy Practices.*
  • HIPAA Consent - Date*
     - -
  • Contact preferences for appointment reminders and dental health information*
  • Should be Empty: