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
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.
Date
Initials
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:
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