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Patient Information

  
Title______  First Name ___________________________________  Last Name_________________________________________
Birth Date____________________________  Social Security #__________________________________ Gender Male  Female
Address__________________________________________________________________ Apartment/Suite___________________
City___________________________________________________________ State___________________ Zip Code____________
Home Phone (_____) - ________________________  Work Phone (_____) - _________________________ Ext________________
Mobile Phone (_____) - ____________________ Fax (_____) __________________ Email_________________________________
Employer_________________________________ Phone (_____) - ___________________ Occupation______________________
Referred by__________________________________________ General Dentist_________________________________________

Person Responsible For Account (If other than patient)
Title______  First Name ___________________________  Last Name__________________________ Date of Birth ____________
Relationship to patient: Patient  Spouse  Child  Other, specify_______________ Social Security #_____________________
Address__________________________________________________________________ Apartment/Suite___________________
City___________________________________________________________ State___________________ Zip Code____________
Home Phone (_____) - ________________________  Work Phone (_____) - _________________________ Ext________________
Mobile Phone (_____) - ____________________ Fax (_____) __________________ Email_________________________________
Employer_________________________________ Phone (_____) - ___________________ Occupation______________________
 

Medical Insurance Information
Insurance Co._______________________________________ Group #_________________ Phone (_____) -__________________
Employer:_________________________________________________________________________________________________
Employee (If other than patient)
Title______  First Name ___________________________________  Last Name_________________________________________
Birth Date______________ Social Security #_______________________ Subscriber#_______________ Gender Male  Female
 

Dental Insurance Information
Insurance Co._______________________________________ Group #_________________ Phone (_____) -__________________
Employer:_________________________________________________________________________________________________
Employee (If other than patient)
Title______  First Name ___________________________________  Last Name_________________________________________
Birth Date______________ Social Security #_______________________ Subscriber#_______________ Gender Male  Female
 
Insurance claims are submitted for our patients as a courtesy. Our services are provided to the patient, not the insurance company. We will attempt to verify coverage whenever possible, however insurance verification is no guarantee of payment. Medicare and Tenncare may not cover the services provided to you (treatment of teeth and gums are not covered by Medicare). If you are covered under these plans and the services are not covered we will look to you for payment. I assign payment directly to Drs. McConnell, Slater, Napier, and Kennedy of the basic benefits as well as Major Benefits here is specified, and otherwise payable to me, but not exceed the regular charges for this period of treatment.
 

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Signature of Patient or Guardian (If patient is a minor)

Date

   

___________________________________________________________

__________________________

Signature Authorized Representative

Date
 
 
 
 
 
 
 
 

Health History
Patients Name: ______________________________ Age______ Height _______ Weight ________ Date_______________
Referring Doctor ___________________________ Primary Doctor ________________________ Did you bring X-Rays? _______
Reason for seeing doctor? ___________________________________________________________________________________

Answer all questions by Circling Yes (Y) or No (N) - All Health History responses are Kept Confidential
01. Are you in good health? Y N
02. Has there been any change in your general health in the past year? Y N
03. Date of last physical exam? __________________________
04. Are you now under a physician's care for any particular problem? Y N
05. Have you ever had any serious illnesses, operations or hospitalizations? Y N
If YES describe______________________________________
__________________________________________________
__________________________________________________
06. Do you have or have you ever had:
A. Rheumatic fever or rheumatic heart disease? Y N
B. Congenital heart disease    
C. Cardiovascular disease (heart attack, heart trouble, heart murmur, coronary artery disease, angina, high blood pressure, stroke, palpitations, heart surgery, pacemaker? Y N
D. Lung disease (asthma, emphysema, COPD, chronic cough, bronchitis, pneumonia, tuberculosis, shortness of breath, chest pain, severe coughing)? Y N
E. Seizures, convulsions, epilepsy, fainting or dizziness? Y N
F. Bleeding disorder, anemia, bleeding tendency, blood transfusion? Do you bruise easily? Y N
G. Liver disease (jaundice, hepatitis)? Y N
H. Kidney disease? Y N
I. Diabetes? Y N
J. Thyroid disease (goiter)? Y N
K. Arthritis? Y N
L. Stomach ulcers or colitis? Y N
M. Glaucoma? Y N
N. Osteoporosis? Y N
O. Implants placed anywhere in your body (heart valve, pacemaker, hip, knee)? Y N
P. Radiation (X-Ray) treatment for Cancer? Y N
Q. Clicking or popping of jaw joint, pain near ear, difficulty opening mouth, grind or clinch teeth? Y N
R. Sinus or Nasal problems? Y N
S. Any disease, drug or transplant operation that has depressed your immune system? Y N
T. Have you been told that you have any of the following: AIDS, HIV, Tuberculosis? Y N
U. Have you been treated for psychiatric care? Y N
Are you using any of the following:
A. Antibiotics? Y N
B. Anticoagulants? Y N
C. Aspirin or drugs such as Motrin, Aleve, Ibuprofen? Y N
D. High blood pressure medications? Y N
E. Steroids (cortisone, prednisone, etc)? Y N
F. Tranquilizers? Y N
G. Insulin or oral anti-diabetic drugs? Y N
H. Digitalis, Inderal, Nitroglycerin or other heart drug?    
I. Are you taking or have you ever taken Bisphosphonates for osteoporosis, multiple myeloma or other cancers (Reclast, Fosamax, Actonel, Boniva, Aredia, Zometa)? Y N
J. Have you ever been advised NOT to take a medication? Y N
List:________________________________________________
___________________________________________________
K. Please list any and all medications taken, including prescription medications, diet drugs, over-the-counter medications, herbal or holistic remedies, vitamins or minerals:____________________
___________________________________________________
___________________________________________________
07. Are you allergic to or have you had an adverse reaction to:
A. Local Anesthesia (Novocain, etc)? Y N
B. Penicillin or other Antibiotics? Y N
C. Sedatives, Barbiturates? Y N
D. Aspirin or Ibuprofen? Y N
E. Codeine or other pain killers? Y N
F. Latex or Rubber products Y N
G. Metal of any kind Y N
H. Chemicals or jewelry (rash or sensitivity)? Y N
I. Food products? Y N
J. Other allergies or reactions? Y N
List:________________________________________________
___________________________________________________
09. Do you smoke or chew tobacco? Y N
How much daily?______________________________________
10. Is there any past history of Alcohol or Chemical Dependency or Emotional Disorder that may affect the care we provide you? Y N
11. Have you had any serious problems associated with any previous dental treatment? Y N
12. Have you or an immediate family member had any problem associated with intravenous anesthesia? Y N
13. Do you have any other disease, condition or problem not listed on this form that you think the doctor should know about? Y N
14. Do you wish to talk to the doctor privately about anything? Y N
15. Have you ever had a bone density scan? Y N
16. For Women Only    
A. Are you pregnant, or is there a chance you might be pregnant? Y N
B. Are you nursing? Y N
C. If you are using Oral Contraceptives, it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Therefore you will need to use mechanical forms of birth control for one complete cycle of birth control pills after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance.    

I understand the importance of a TRUTHFUL and COMPLETE Health History to assist my dentist in providing the best care
possible. I've had the opportunity to discuss my Health History with my dentist
_________________ ___________________________________________________ _________________
Date Signature of Person Completing Health History Doctor's Initials
 

 
   

 

Consent for use and Disclosure of Health Information

Section A: Patient Giving Consent
 
Patients Name: _______________________________________ Social Security # ______________________________________
 

Section B: To the Patient - Please Read the Following Statement
 
Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected Health Information to carry our Treatment, Payment Activities and HealthCare Operations.
 
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 disclosure we may make of your protected health information, and of other important matters about the right to change our privacy practices as described in our Notice of Privacy Practices. A copy of our Notice of Privacy Practices accompanies this Consent. 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 Protected Health Information that we maintain.
 
I have had full opportunity to read and consider the contents of this Consent Form. I understand that, by signing this Consent Form, I am giving my consent for your use and disclosure of my Protected Health Information to carry out Treatment, Payment Activities, and HealthCare Operations.
 
I have received a copy of this office's Notice of Privacy Practices   YES     NO  (Please circle one)
 

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Patient's Signature

Date

   

___________________________________________________________

__________________________

Personal Representative's Signature

Date
   

___________________________________________________________

  

Personal Representative's Relationship to Patient

  
 
________ We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained. Reason:_______________________________________________________________________________________
 

At any time you have the right to revoke consent to disclose your HealthCare information
 

Southeast Oral Surgery
Maryville Office: Phone 865-977-7110 Fax: 865-977-4132   /   Seymour Office: Phone 865-577-7800 Fax: 865-934-6989