Welcome to Wallingford Smilemakers Welcome to our Dental

 Welcome to Wallingford Smilemakers Welcome to our Dental Wellness Center! We practice overall body health and the oral connection to wellness. I am pleased to announce the integration of this philosophy into our current oral healthcare program. Your first visit will be the ultimate patient experience! This experience was designed with the help of a team of medical internists and is core to establishing a healthy mouth baseline. Today, the knowledge and supporting data is conclusive. Proactive, healthy, mouth care will directly reduce the risk of: • Cancer • Cardiovascular disease • Stroke • Diabetes • Obesity • Other Systemic diseases Click here to watch the video or visit: http://tinyurl.com/mj74fe7
The link between oral healthcare and total body wellness is created by establishing a healthy mouth baseline for each patient and developing a treatment program for improvement and maintenance. We all want to live longer, healthier lives. By incorporating this philosophical shift in the treatment of each of our patients, we can now play a more important role beyond teeth and gums in helping you achieve the goal of total body wellness. To your good health, Dr. Ron Hayes One Chester Road • Wallingford, PA • 610-­‐874-­‐5700 • www.WallingfordSmilemakers.com NP Date
_____ /_____ /_____
Name
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Patient First
Welcome
&Last
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Patient Welcome & Registration
Registration
2
Patient
Information
Date:_______ /_______ /_______
Name:
_______________________________ _________________________ Birthdate: ____ /____ /_____
First
MI
Last
Soc.Sec #: _________ - _______ -__________ License #:___________________ Age: _____ Sex: _____
Address:
_______________________________________________________________________ ���������
Apt #
________________________________________________________ _______________ ������������������
City
State
Home Phone: ________ - _________ - ____________
Zip
Cell: ________ - _________ - ____________
Work Phone: ________ - _________ - ____________ Email:�����������������������������������
Employer:
_____________________________________ Occupation:������������������������������
Method of Appointment confirmation: Phone: ■ Home ■ Cell ■ Work or ■ email
How did you hear about us:■ Online/Internet
■ Mail
■ Insurance
■ Sign
■ Referral whom __________________________________________________
■ Other _____________________________________________________________
Responsible _ ■ Patient (same as above) ■ Parent or Guardian If responsible party is other than the patient:
PartyName:
_______________________________ _________________________ Birthdate: ____ /____ /_____
First
MI
Last
Information
Who Will
Pay The Bill
Soc.Sec #: _________ - _______ -__________ License #:___________________ Age: _____ Sex: _____
Address
_______________________________________________________________________ ���������
Apt #
________________________________________________________ _______________ ������������������
City
State
Zip
Home Phone: ________ - _________ - ____________ TEXT: ________ - _________ - ____________
Work Phone: ________ - _________ - ____________ Email:�����������������������������������
Employer:
_____________________________________ Occupation:������������������������������
DentalI AM INTERESTED IN FINANCING OPTIONS?_ ■ Yes ■ No
Insurance
Insured’s Name_________________________________________ Relationship: �����������������
Information Insured’s employer ����������������������������������������������������������������������
Insured’s Soc.Sec # ____________________________________________ Birthdate: ____ /____ /_____
Insurance Company����������������������������������������������������������������������
Group # _____________________________________ Local # ������������������������������������
State________________________________________________ Zip__________________
please select the quality of care you most desire:
■ B
EST TREATMENT FOR OVERALL
WELLNESS (Health Imperative)
■ B
EST TREATMENT FOR OVERALL WELLNESS
(Cosmetic Appearance & Health Imperative)
2
■ O
NLY TREATMENT COVERED BY
MY DENTAL PLAN (Often Minimal)
EmergencyName:
_______________________________________________ Relationship: ���������������������
Contact
Address:
_______________________________________________________________________ ���������
Apt #
_______________________________________________________ _______________ ������������������
City
State
Home Phone: ______ - ________ - ___________
Zip
Cell: ________ - _________ - ____________
Work Phone: ______ - ________ - ___________ Are they a Current Patient?: ■ Yes ■ No
Medical
History
1.What Medications are you currently taking (circle those that are daily)?������������
���������������������������������������������������������������������������
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2. Over the counter Medications?�����������������������������������������������
3. Other (i.e. joint replacement): ������������������������������������������������
4. Are you aware of being allergic to any other medications or substances? Please list:
���������������������������������������������������������������������������
5. Please Check the following boxes if you have had or have the following
■ Acid Reflux
■ Fainting
■ Nervous Problems
■ AIDS/HIV Pos.
■ Food Allergies
■ Pacemaker/heart surgery
■ Anaphylaxis
■ Glaucoma
■ Psychiatric care
■ Anemia
■ Headaches
■ Arthritis
■ Head/Neck
■ Radiation Treatment
■ Artificial Heart Valves
■ Artificial Joints
■ Heart Murmur
■ Asthma
■ Heart Problems
■ Atopic Allergy Prone
Describe:
■ Back Problems
_____________________
■ Blood disease
■ Bulimia
■ Hemophilia
Abnormal bleeding
■ Rapid Weight Loss/Gain
■ Respiratory Disease
■ Rheumatic/Scarlet Fever
■ Shingles
■ Shortness of breath
■ Sjögren’s Syndrome
■ Skin rash
■ Cancer
■ Hepatitis
■ Spinal Bifida
■ Chemical Dependency
■ Herpes
■ Stroke
■ Chemotherapy
■ High Blood Pressure
■ Circulatory Problems
■ Jaw Pain
■ Surgical Implant
■ Cold Sores
■ Kidney Disease
■ Cortisone Problems
Radiation Therapy
malfunction
■ Cortisone Treatments
■ Liver disease
■ Cough
■ Material allergies
■ Swelling of feet
or ankles
■ Thyroid disease
malfunction
■ Cough Up Blood
LIst:
■ Tobacco habit or use
■ Diabetes
_____________________
■ Tuberculosis
■ Epilepsy
■ Mitral valve prolapse
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■ Venereal Disease
6. Is there any other medical or dental information we should know about?
���������������������������������������������������������������������������
7. Family Physician: ������������������������������������������������������������
Address & phone:�����������������������������������������������������������
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8. Do you have any current medical problems?������������������������������������
9. Are you Pregnant?
10. Are you under a Physician’s care now?
11. For what?������������������������������������������������������������������
12. Do you use:
13. Are you allergic to or have you reacted adversely to any of the following medications:
■ Cigars
■ Cigarettes
■ Pipe
■ Yes
■ No
■ Yes
■ No
■ Chewing Tobacco
■ Aspirin
■ Codeine
■ Latex (Gloves, Balloons ext.)
■ Nitrous Oxide
■ Erythromycin
■ Other:
■ Local Anesthetic
■ Penicillin
��������������������������������������
14. Do you notice plaque build-up on your teeth?
■ Yes
■ No
15. Daily Medications? If yes, how many? (#____ )?
■ Yes
■ No
16. Do you feel like you have dry mouth at any time
■ Yes
■ No
■ Yes
■ No
of the day or night?
17. Do you drink liquids other than water more than
2 times daily between meals?
19. Do you snack daily between meals?
■ Yes
■ No
20. Do you have oral appliances present?
■ Yes
■ No
21. Do you use other drugs?
■ Yes
■ No
Dental History
It is Important that we know about your Medical and Dental History.
T hese facts have a direct bearing on your Dental Health. This Information is strictly confidential and
will not be released to anyone. Thank You for taking the time to completely fill out this questionnaire.
1. Last dentist visit (approximate):
2. Last COMPLETE Dental Exam Date: _______ /_______ /_______
_______ /_______ /_______
3. Last FULL MOUTH X-RAYS date:
_______ /_______ /_______
4. Name of previous dentist: ���������������������������������������������������
Address & phone:�����������������������������������������������������������
5. What is the reason for this visit? ����������������������������������������������
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6. Are you having problems now? If yes, please explain:����������������������������
���������������������������������������������������������������������������
4
Please rank how the following would keep you from having dental treatment.
Dental
(CIRCLE APPROPRIATE NUMBER)
History
7. Fear
(continued)
MOST < --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------
1
2
3
4
> LEAST
5
8. Cost
MOST < --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- > LEAST
1
2
3
4
5
9. Missing time from work
MOST < --------------------------------------------------------------------------------------------------------------------------------------------------------------------------------- > LEAST
1
2
3
4
5
10. Other
���������������������������������������������������������������������������
11. Please Check the following boxes Yes or No:
Yes
No
Do you drink bottled water?
■
■
Is your present dental health poor?
■
■
If you wear dentures are you unhappy with them?
■
■
Have you ever had any periodontal (gum) treatments?
■
■
Do your gums bleed, or feel tender or irritated?
■
■
Are your teeth sensitive to hot, cold, sweets, pressure?
■
■
Are you aware of grinding or clenching your teeth?
■
■
Do you have headaches, earaches, or neck pains?
■
■
Have you worn braces on your teeth? (orthodontics)
■
■
Do you have discolored teeth that bother you?
■
■
Have you ever been diagnosed with Sleep Apnea?
■
■
Have you ever had an overnight sleep study?
■
■
Do you or have you used a CPAP?
■
■
Do you wake up in the morning with headaches?
■
■
■
■
■
■
Have you been told that you gasp for air or
suddenly stop breathing while sleeping?
Do you snore?
5
Dental
History
(continued)
12. A
re you unsatisfied with (Check all that apply):
■ Alignment
■ Spacing
■ Color
■ Shape
■ Previous Dental Work
Explain��������������������������������������������������������������������
���������������������������������������������������������������������������
13.What would you like to change the most in the appearance of your teeth?
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14. How would you like your teeth to look?
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���������������������������������������������������������������������������
15.Would you like your teeth to be whiter? ■ Yes
16.Do you use a Power Brush? ■ Yes
■ No
■ No
If so, which one(s)________________________________________________________
Clinical
Use Only
DISEASE INDICATORS
■ Yes
■ No
New/Progressing Approximal Radiographic Radiolucencies? ■ Yes
■ No
New/Active White Spot Lesions?
■ Yes
■ No
Decay History is a Concern? ■ Yes
■ No
Risk Factors are a Concern? ■ Yes
■ No
Disease indicators are a Concern? ■ Yes
■ No
New/Progressing Visible Cavitations? PROFESSIONAL ASSESSMENT SUMMARY
RISK IDENTIFICATION Transfer information above to boxes below to determine risk.
Y N
Y N
Y N
Y N
Y N
■ ■ Risk Factors
■ ■ Risk Factors
■ ■ Risk Factors
■ ■ Risk Factors
■ ■ Risk Factors
■ ■ Disease Indicators ■ ■ Disease Indicators ■ ■ Disease Indicators ■ ■ Disease Indicators ■ ■ Disease Indicators
LOW RISK
MODERATE RISK
HIGH RISK
HIGH RISK
HIGH/EXTREME RISK
1
2
3
4
5
■ RECOMMENDED
■ PROVISIONAL
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■ DECLINE
Notice of Financial Practices
FINANCE CHARGES
Charges not paid within 60 days of their original billing will be subject to a finance charge of 1% per month (12% per annum). In the event that a portion
of your bill is left unpaid, we will provide you with a statement of balance due. Charges not paid 90 days of the original billing are automatically referred to
collection, if your account is referred to collection, you will be responsible for collection costs in the amount of 30% of the outstanding balance, together with
court costs and reasonable attorney’s fees.
FINANCIAL POLICY
As you may know, your dental insurance does not always cover the cost of your treatment. In these instances, you may be financially responsible for your
treatment. To keep our fees to you as low as possible, we ask that you pay your co-payment at the time you receive treatment. Please indicate your preferred
method to use to pay your dental treatment, including your co-payment:
■ Credit Card
■ Cash
■ Check
■ I would like to know more about financing my treatment
COMMITMENT TO APPOINTMENT
An appointment in our schedule is a bond of trust that we will be there to serve you and you will be present for treatment. Our office has to be firm in this
regard and we cannot tolerate frequent cancellations or short notice changes. A scheduled appointment may suddenly become an inconvenience to you, but
to cancel without adequate notice imposes a severe financial burden on this office and is inconsiderate of other patients needing an appointment. We request
appointments to be cancelled within 48 hours, 2 business days to avoid a scheduling deposit.
HIPPA Policy - Notice of Privacy and Practices
This notice describes how health information about you may be used and disclosed 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
Federal and state law requires us to maintain the privacy of your health information. That law also requires us 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 we describe while it is in effect. This notice takes
effect April 14, 2003, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this notice any time, provided such applicable law permits the changes. 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 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 health care operations. For example:
TREATMENT: We may use your health information for treatment or disclose it to a dentist, physician or other health care provider providing treatment to you.
PAYMENT: We may use and disclose your health information to obtain payment services we provide to you. We may also disclose your health information to
another health care provider or entity that is subject to the federal Privacy Rules for its payment activities.
HEALTH CARE OPERATIONS: We may use and disclose your health information for our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance,
conducting training programs, accreditation, and certification, licensing or credentialing activities. We may disclose your information to help these organizations conduct quality assessment and improvement activities, review the competence or qualifications of health care professionals, or detect or prevent health
care fraud and abuse.
ON YOUR AUTHORIZATION: You may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give
us authorization, you may revoke it in writing at any time. Your revocation will not affect any uses or disclosure 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 AUTHORIZATION: You may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give
us authorization, you may revoke it in writing at any time. Your revocation will not affect any uses or disclosure 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 may disclose your health information to a family member, friend or other person to the extent necessary to help with
your health care or with payment for your health care. Before we disclose your health information to these people, we will provide you with an opportunity to
object to our use or disclosure. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on
your professional judgment of whether the disclosure would be in your best interest. We may 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, e-rays, or other similar
forms of health information. We may use or disclose information about you to notify or assist in notifying a person involved in your care, of your location and
general condition.
APPOINTMENT REMINDERS: We may use or disclose your health information and appointment activity to provide you with appointment reminders (such
as voicemail messages, postcards, or letters).
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DISASTER RELIEF: We may use or disclose your health information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.
PUBLIC BENEFIT: We may use or disclose your medical information as authorized by law for the following purposes deemed to be in the public interest or benefits:
• as required by law
• a nd as authorized by state worker’s compensation laws
• for public health activities, including disease and vital statistic reporting,
child abuse reporting, FDA oversight, and to employers regarding workrelated illness or injury
• t o law enforcement officials pursuant to subpoenas and other lawful
processes, concerning crime victims, suspicious deaths, crimes on your
premises, reporting crimes in emergencies, and for purpose of identifying
or locating a suspect or other person
• to report abuse, neglect, or domestic violence
• to health oversight agencies
• in response to court and administrative orders and other lawful processes
• t o the military and to federal officials for lawful intelligence, counterintelligence, and national security activities
• to avert a serious threat to health or safety
• t o correctional institutions regarding inmates
• to coroners, medical examiners, and funeral directors
• in connection with certain research activities
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
health information. You may request by sending us a letter to the address at the end of this notice. If you request copies, we will charge you a reasonable
cost-based fee that may include labor, coping costs and postage. If you request an alternate format, we will charge a cost-based fee for providing your health
information in that format. If you prefer, we may but are not required to prepare a summary or an explanation of your health information for a fees.
DISCLOSURE ACCOUNTINGS: You have the right to receive a list of instances in which we or our business associates disclosed your health information over
the last 6 years (but not before April 14, 2003). That list will not include disclosures for treatment, payment, health care operations, as authorized by you, and
for certain other activities. 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. Contact us using the information listed at the end of this notice for more information about fees.
RESTRICTION: you have the right to request that we place additional restriction 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). Any agreement we may make to a request for
additional request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. Your request is not
binding unless our agreement is in writing.
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 your request in writing. You must specify in your request the alternative means or location, and provide satisfactory
explanation how you will handle payment 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 we should
amend the information. We may deny your request under certain circumstances. Mail all request to:
Privacy Officer
Wallingford Smilemakers
One Chester Road
Wallingford, PA 19086
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed above.
If you believe that:
• we may have violated your privacy rights
• we made a decision about access to your health information incorrectly
• our response to a request you made to amend or restrict the use or disclosure of your health information was incorrect
• or, we should communicate with you by alternative means or at alternative locations
You may contact us using the information listed above. 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 a complaint with the U.S. Department of Health and Human Services upon request. We support your right to the
privacy of your health information. We will not retaliate in any waxy if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
By signing below I hereby authorize this office to affix my name to any and all claims or documents as related to any and all health benefits due to me and my
dependents through my employment. I hereby authorize payment of dental benefits otherwise payable to me, directly to this dental office.
This “Signature of File” will be valid from this date and shall renew in one year of, unless I cancel the authorization through written notice to this office.
A photocopy of this document may act as an original.
The undersigned hereby authorizes the Doctor to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by Doctor to make
a thorough diagnosis of the patient’s dental needs. I also authorize Doctor to perform any and all forms of treatment, medication, and therapy that may be
indicated. I also understand the use of anesthetic agents embodies a certain risk. I understand that my dental insurance is a contract between me and the
insurance carrier, and not between the insurance carrier and the Doctor and that I am still fully responsible for all dental fees. These fees are due and payable
at the time services are rendered unless prior financial arrangements have been made. I also assign all insurance benefits to the Doctor. Any payments received
by the Doctor from my insurance coverage will be credited to my account, or refunded to me if I have paid the dental fees incurred. I further understand that
a late charge will be added to any overdue balance. I understand that where appropriate, credit reports may be obtained.
I acknowledge that I have read and understand the privacy practices explained in the notice of privacy practices.
Patient Signature (Guardian of child):������������������������������������������ Date: ____ /____ /_____
Dentist Signature:��������������������������������������������������������������� Date: ____ /____ /___
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SM092613
Ultimate Patient Experience Check List
Dr. Ron Hayes and his team provide a completely different kind of dentistry. We are committed
to your overall health and wellness and the connection to oral health. We have created the
ultimate new patient experience. In a comfortable and relaxed environment, we will leave you
with a sense of personal care and treatment targeted specifically for you. Here’s a list of
everything we will cover in your first visit:

Medical History Review

Patient Questions and Concerns

Intra and Extra Oral Cancer Screening

Periodontal Exam

General Intraoral Observation
● Radiographs

Intra Oral Photos or Flash Mouth Tour
● Share Healthy Baseline Report
● Doctor’s Oral Health Diagnosis and Treatment Plan