Tomas Anderkvist D.D.S New Patient Information Westwood Dental Smiles Welcome to our practice Please take your time to fill out this form completely. The more we learn about you, the better care we are able to provide. We look forward to working with you to maintain a healthy happy smile. Patient Information Today's date First Name Middle Initial Last Name I prefer to be called (nickname,etc.) Male Female Address City State ZIP Date of birth Social Security Number Home phone Work phone Cell phone Primary contact number (please check one) Home Office Cell Best time to call Fax Email Drivers license # Employer Occupation Spouse's name Spouse's Occupation Whom may we thank for referring you? If the patient is a child School School phone Grade Dental History Reason for today's visit Are you currently in pain? Yes No If so, please describe: Do you have any dental problems now? Yes No If so, please describe: Have you ever had trouble with a previous dental treatment? Yes No If so, please describe: Level of anxiety about seeing the dentist (least) 1 2 3 4 5 (most) Date of last dental exam Date of last cleaning Date of last full mouth X-Rays Procedure(s) done at last dental visit Previous dentist's name City State phone Why are you changing dentists? How often do you have dental examinations? How often do you brush your teeth? How often do you floss? What type of bristles do you use? Hard Medium Soft What other dental aids do you use? (Electric toothbrush, toothpick, etc.) Yes No Do you require antibiotics before dental treatment? Do your gums ever bleed? Have you noticed any mouth odors or bad taste? Do you bite your lips or cheeks frequently? Yes No Do you have frequent headaches? Do you clench or grind your teeth? Are your teeth sensitive to heat/cold? Do you still have your wisdom teeth? Tomas Anderkvist D.D.S New Patient Information Westwood Dental Smiles Have you ever had: Have you ever had: Yes No Periodontal disease/gum treatment Orthodontics treatment Oral surgery A bite plate or mouth guard Yes No Discomfort in your jaw joint (TMJ/TMD) Your teeth ground or bite adjusted Serious injury to the mouth or head Bad Experience in a dental office If yes to any of the previous questions, please describe Is there anything else about your past dental treatment(s) that you would like us to know? Patient Information Have you been hospitalized or under the care of a medical doctor during the past two years? Yes No If yes, for what? Hospital or Physician's name phone Have you taken any medications or drugs in the past two years? Yes No Are you currently taking any medications or drugs? (example: blood thinners, blood pressure meds, antibiotics, aspirin, herbs) Yes No If yes,please explain Have you ever taken Fen-Phen (Diet Drug), Biphosphonates medication for osteoporosis like Fosamax, Boniva...? Yes No If yes,please explain Do you use tobacco in any form? Yes No Do you use alcohol or any other controlled substance? Yes No Women Only: Yes No Are you pregnant or thinking you may be pregnant? Are you taking birth control pills? Yes No Are you nursing? Indicate which of the following you have had or have at present: Yes No AIDS/HIV Alcohol/Drug Abuse Allergies or Hives Anemia Arthritis/Rheumatism Artificial Heart Valve Artificial Bones/Joints Asthma Blood Disease Blood Transfusion Bruise Easily Cancer/Chemotherapy Chest Pain Cold Sores/Herpes Colitis Contact Lenses Cortisone Medicine Diabetes Diet (Special/Restricted) Yes No Difficulty Breathing Emphysema Epilepsy or Seizures Fainting or Dizzy Spells Frequent Headaches Glaucoma Hay Fever Heart (Surgery, Disease, Attack) Heart Pacemaker Heart Murmur Hemophilia/Abnormal Bleeding Hepatitis If Yes Hepatitis A B C High/Low Blood Pressure Hospitalized for Any Reason Jaundice Kidney Trouble Liver Disease Yes No Lupus Mitral Valve Prolapse Nervousness/Anxiety Neurological Disorders Psychiatric/Psychological Care Radiation Therapy Rheumatic/Scarlet Fever Shingles/Chicken Pox Sickle Cell Disease/Traits Sinus Trouble Snoring/Sleep Apnea Stomach Problems/Ulcers Stroke Swollen Ankles Thyroid Problems Tuberculosis (TB) Tumors Venereal Disease/STD/HPV Please list any serious medical condition(s) that you have ever had not listed above: Are you aware of having an allergic (or adverse) reaction of the following: Yes No Aspirin Codeine Anesthetics (i.e. Novocaine) Erythromycin Bleach Alcohol BPA Kadmium Nickel Resins Yes No Iodine Jewelry/Metals Latex Penicillin or other antibiotics Silver/Gold Mercury Cobalt-Chrom Acrylic ESTA (ethylenediaminetetraacetic) Formaldehyde Yes No Sedatives Sulfa Drugs Tetracycline Phosphoric Acid Methyl Methacrylate Zinc Oxide Eugenol Mineral Trioxide Aggregate Calcium Hydroxide Gutta Percha Nsaids (Ibuprofen) Other Patient Signature Tomas Anderkvist D.D.S New Patient Information Westwood Dental Smiles Dental Insurance Primary Carrier Insurance co. name Insurance co. phone Address (Street) City State ZIP Group no. (Plan or Policy no.) Insured's I.D. no. Insured's name Relationship to patient Date of birth Insured social security no. Insured employer name Is insured a patient in our practice? Yes No Secondary Carrier Insurance co. name Insurance co. phone Address (Street) City State ZIP Group no. (Plan or Policy no.) Insured's I.D. no. Insured's name Relationship to patient Date of birth Insured social security no. Insured employer name Is insured a patient in our practice? Yes No Person Financially Responsible for Account Name Relationship to patient Social security no. Phone Drivers license no. Date of birth Address (Street) City State ZIP Employer Work phone Preferred payment method Cash Credit Card Visa/MC/AMEX no. Exp. date If patient is a minor, name of parent or legal guardian and relationship Is insured a patient in our practice? Yes No Payment is due in full at the time of treatment (Unless prior arrangements have been approved) I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductibles that my insurance does not cover. I hereby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize release of any information including the diagnosis and records of treatment or examination rendered, to my insurance company. I the undersigned, hereby authorize the office listed below to charge my credit card for charges not covered on the insurance. I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective healthcare provider or agency that may release such information to you. I will notify the dentist of any changes in my health or medication. Signature Date I agree by electronic signature to be contacted by Westwood Dental Smiles through an automated SMS text at my cellular number to review and pay my bill. Signature Date Person to contact in case of emergency Name Relationship to patient City State Cell Phone Home Phone Work Phone OFFICE USE ONLY I VERBALLY REVIEWED THE MEDICAL/DENTAL INFORMATION ABOVE WITH THE PATIENT NAMED HEREIN. Initals:_____________________ Date:________________________ Tomas Anderkvist D.D.S Smile Analysis Westwood Dental Smiles Today's Date Patient Number 1. Do you love the way your smile looks? Yes No 2. Do you feel comfortable showing your teeth when you laugh or smile? Yes No 3. If you could change anything about your smile, it would be (Check all that apply): Color of your teeth Size/Shape of your teeth Too much or too little of teeth show when you smile Too much or too little of gum shows when you smile Gaps between your teeth Alignment of your teeth Other: 4. Do you have (Check all that apply): Sensitive or receding gums Old or discolored fillings Worn/broken/chipped teeth Old crowns that have dark edges at the top Missing teeth Other: 5. In your line of work or lifestyle, do you (Check all that apply): Visit businesses or clients Travel Speak publicly Other: 6. If you had a smile makeover do you think you'd feel (Check all that apply): More confident Just OK More optimistic No different Healthier Other 7. Do you or someone in your family have issues with any of the following (Check all that apply): Chronic bad breath Grinding teeth Snoring Other: We'd Like to know more about you so we can better serve you ! 8. Do you prefer appointments in the (Check all that apply): Early morning Late morning Early afternoon Late afternoon No preference Other: 9. Do you have any special dates or upcoming events you'd like us to remember? (weddings, graduations, etc.) 10. What type(s) of music do you enjoy? (Optional) Easy Listening Jazz Classical Country Rock R&B Hip-Hop/Rap Other: 11. What are your favorite hobbies or activities (Optional) 12. Is there anything else that you want our office to know about you that will help us to serve you better? HIPAA Privacy Rule of Patient Authorization Agreement Authorization for the Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.508(a)) I, (Patient's Name) understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I understand that this information serves as: • a basis for planning my care and treatment; • a means of communication among the health professionals who may contribute to my health care; • a source of information for applying my diagnosis and surgical information to my bill; • a means by which a third-party payer can verify that services billed were actually provided; • a tool for routine health care operations such as assessing quality and reviewing the competence of health care professionals. I have been provided with a copy of the Notice of Privacy Practices that provides a more complete description of information uses and disclosures. I understand that as part of my care and treatment it may be necessary to provide my Protected Health Information to another covered entity. I have the right to review this facility's notice prior to signing this authorization. I authorize the disclosure of my Protected Health Information as specified below for the purposes and to the parties designated by me. Privacy Rule of Patient Consent Agreement Consent to the Use and Disclosure of Protected Health Information for Treatment, Payment, or Healthcare Operations (§164.506(a)) I understand that: • I have the right to review this facility's Notice of Information practices prior to signing this consent; • that this facility reserves the right to change the notice and practices and that prior to implementation will mail a copy of any notice to the address I've provided, if requested; • I have the right to object to the use of my health information for directory purposes; • I have the right to request restrictions as to how my Protected Health Information may be used or disclosed to carry out treatment, payment, or healthcare operations, and that this facility is not required by law to agree to the restrictions requested; • I may revoke this consent in writing at any time, except to the extent that this facility has already taken action in reliance thereon. Signature of Patient or Legal Representative Witness: Printed Name of Patient or Legal Representative Witness: Date: HIPAA Privacy Rule Receipt of Notice of Privacy Practices Written Acknowledgement Form Acknowledgement of Receipt of Information Practices Notice (§164.520(a)) I, (Patient's Name) understand that as part of my healthcare, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I acknowledge that I have been provided with and understand this facility's Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I understand that: • I have the right to review this facility's Notice of Privacy Practices prior to signing this acknowledgment; • this facility reserves the right to change their Notice of Privacy Practices and prior to implementation of this will mail a copy of any revised notice to the address I've provided, if requested. Signature of Individual or Legal Representative Witness: Printed Name of Individual or Legal Representative Witness: Date: FOR OFFICE USE ONLY We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but it could not be obtained because: • Individual refused to sign • Communication barrier prohibited obtaining the acknowledgement • An emergency situation prevented us from obtaining acknowledgement • Other (please specify) Privacy Official: Date: Please enter code above in the field below.