Thank you for trusting us with your dental care. We are committed to provide you with the finest care available. If you have any questions please do not hesitate to ask us.
Patient Name: Account #: DOB:
PATIENT INFORMATION
Name Birthdate Cell Phone
Address City State Zip
Gender ☐M ☐F ☐Minor If yes, Guardian’s Name
E-mail Home Phone
☐ Join our mailing list for news, announcements and special promotions.
Employer/School Employer/School Phone
Employer/School Address City State Zip
Spouse/Guardian Employer Cell Phone
Emergency Contact Cell Phone
☐ I authorize Cunning Dental Group to send me text messages related to my dental health (standard text message fees may apply).
RESPONSIBLE PARTY
Name of Person Responsible for this Account Relationship to Patient
Address City State Zip
Driver’s License # Birthdate Employer
Social Security #
Cell Phone Work Phone Home Phone
Currently a patient in our office? ☐Yes ☐No E-mail
INSURANCE INFORMATION
Name of Insured Relationship to Patient
Birthdate Social Security # Date Employed
Employer Work Phone
Employer Address City State Zip
Insurance Company Member ID # Union or Local #
Cunning Dental Group (877)41-SMILE PATIENT INFORMATION FORM 0619 Page 1 of 2 ADDITIONAL INSURANCE
Name of Insured Relationship to Patient
Birthdate Social Security # Date Employed
Employer Work Phone
Employer Address City State Zip
Insurance Company Member ID# Union or Local #
DENTAL HISTORY
Reason for today’s visit
Concern regarding smile/teeth:
Are you here for a second opinion? ☐ Yes. Reason: ☐ No
Former Dentist Date of last dental visit
Dentist’s Address City State Zip
Check (☒) if you have had problems with any of the following: ☐ Bad breath ☐ Bleeding gums ☐ Clicking or popping jaw ☐ Food collection between the teeth ☐ Grinding teeth ☐ Loose teeth or broken fillings ☐ Periodontal treatment ☐ Sores or growths in your mouth ☐ Sensitivity to hot ☐ Sensitivity to sweets ☐ Sensitivity when biting ☐ Sensitivity to cold
How often do you floss? How often do you brush?
Do you feel you require? ☐ Nitrous Oxide ☐ IV Conscious Sedation ☐ General Anesthesia (Laughing Gas) (Sleep Dentistry) (with an Anesthesiologist)
REFERRAL INFORMATION
INTERNET RADIO TELEVISION OTHER
☐ Facebook ☐ KEIB Patriot 1150 AM ☐ ABC 7 ☐ Dentist Referral, ☐ Google ☐ KFI 640 AM ☐ FOX 11 please provide name ☐ Instagram ☐ KLAC Sports 570 AM ☐ TV Unknown ☐ Employee Referral, ☐ Our Website ☐ KNX 1070 AM please provide name ☐ Yelp ☐ KOGO San Diego ☐ Insurance Plan ☐ Radio Unknown ☐ Patient Referral, please provide name ☐ Print ☐ Unknown ☐ Valpak
Cunning Dental Group (877)41-SMILE PATIENT INFORMATION FORM 0619 Page 2 of 2 Patient Name: Account #: DOB: MEDICAL HISTORY Name of physician/their specialty: Most recent physical examination: Purpose: Name of pharmacy/phone/address: Age: Height: Weight: Today’s BP: O2Sat: YES NO 1. ☐ ☐ Hospitalization for illness or injury (if yes, explain)
2. ☐ ☐ Heart problems 3. ☐ ☐ Cardiac stent within the last six months 4. ☐ ☐ History of Endocarditis (heart infection) 5. ☐ ☐ Artificial heart valve, repaired heart defect (PFO) 6. ☐ ☐ Pacemaker or implantable defibrillator 7. ☐ ☐ Orthopedic implant (joint replacement) 8. ☐ ☐ High blood pressure 9. ☐ ☐ Low blood pressure 10. ☐ ☐ A stroke (taking blood thinners) 11. ☐ ☐ Anemia or other blood disorder 12. ☐ ☐ Prolonged bleeding due to a slight cut (INR>______) 13. ☐ ☐ Emphysema, shortness of breath, sarcoidosis 14. ☐ ☐ Tuberculosis, measles, chicken pox 15. ☐ ☐ Asthma 16. ☐ ☐ Breathing or sleep problems (i.e. sleep apnea, snoring, sinus) 17. ☐ ☐ Kidney disease 18. ☐ ☐ On dialysis 19. ☐ ☐ Liver disease 20. ☐ ☐ Thyroid, parathyroid disease, or calcium deficiency 21. ☐ ☐ Hormone deficiency 22. ☐ ☐ High cholesterol or taking statin drugs 23. ☐ ☐ Diabetes (HbA1c) A1C______24. ☐ ☐ Stomach or duodenal ulcer 25. ☐ ☐ Digestive disorders (i.e. celiac disease, gastric reflux) 26. ☐ ☐ Gastric bypass/sleeve 27. ☐ ☐ Osteoporosis / osteopenia (i.e. taking bisphosphonates) ☐ IV ☐ Pills How long ago? ______For how long? ______28. ☐ ☐ Arthritis 29. ☐ ☐ Autoimmune disease (i.e. rheumatoid arthritis, lupus, scleroderma) 30. ☐ ☐ Head or neck injury 31. ☐ ☐ Epilepsy, convulsions (seizures) 32. ☐ ☐ Neurologic disorders (ADD, ADHD, prion disease) 33. ☐ ☐ Cold sores 34. ☐ ☐ Any lumps or swelling in the mouth 35. ☐ ☐ Hives, skin rash, hay fever 36. ☐ ☐ STI / STD / HPV 37. ☐ ☐ Hepatitis (type A, B or C)
Cunning Dental Group (877)41-SMILE MEDICAL HISTORY 0719 Page 1 of 2 YES NO 38. ☐ ☐ HIV / AIDS (T-cell (CD4) count ______) 39. ☐ ☐ Tumor, abnormal growth, cancer Type ______40. ☐ ☐ Radiation therapy. Area ______When______Frequency______41. ☐ ☐ Chemotherapy, immunosuppressive medication 42. ☐ ☐ Emotional difficulties 43. ☐ ☐ Psychiatric treatment 44. ☐ ☐ Antidepressant medication 45. ☐ ☐ Alcohol / Recreational drug use / Marijuana Are you? 46. ☐ ☐ Presently being treated for any other illness If yes, what is it? ______47. ☐ ☐ Aware of a change in your health in the last 24 hours (i.e. fever, chills, new cough, diarrhea) 48. ☐ ☐ Taking medications for weight management 49. ☐ ☐ Taking dietary supplements 50. ☐ ☐ Often exhausted or fatigued 51. ☐ ☐ Experiencing frequent headaches 52. ☐ ☐ A smoker/vaper. How many/much per day? ______53. ☐ ☐ Chewing tobacco 54. ☐ ☐ Taking birth control pills 55. ☐ ☐ Currently pregnant 56. ☐ ☐ Taking medication for erectile dysfunction (i.e. Viagra, Cialis, or other medication) 57. ☐ ☐ Taking blood thinners An allergic reaction to: Aspirin Tetracycline Ibuprofen (Advil/Motrin) Sulfa Acetaminophen (Tylenol) Local Anesthetic Codeine Fluoride Penicillin Metals (Nickel, Gold, Silver) Erythromycin Latex Other ______
Is there any other medical issue we should be aware of?
List all medications, supplements, and or vitamins taken currently (use additional pages if necessary).
Drug Purpose Drug Purpose
Signature of Patient or Legal Representative Date Doctor’s Signature Date
Changes in health since last seen? ______Patient’s Initials: ______Date: ______
Dr.’s Initials: ______Date: ______BP Reading: ______
Changes in health since last seen? ______Patient’s Initials: ______Date: ______
Dr.’s Initials: ______Date: ______BP Reading: ______PLEASE ADVISE US IN THE FUTURE OF ANY CHANGE IN YOUR MEDICAL HISTORY OR ANY MEDICATIONS YOU MAY BE TAKING.
Cunning Dental Group (877)41-SMILE MEDICAL HISTORY 0719 Page 2 of 2
Patient Name: Account #: DOB:
HIPAA / INSURANCE RELEASE / NOTICE OF PATIENT RESPONSIBILITY
HIPAA: Consent of Disclosure I hereby give consent to CUNNING DENTAL GROUP (CDG) to use and disclose my protected health information for the purpose of treatment, payment and health care operations. You may cancel this consent at any time. Your cancellation must be in writing, signed by you or on your behalf, and it will only be effective when we actually receive it. You have the right to request restriction on the usage and disclosure of your protected health information for the purpose of treatment, payment or health care operations. We are not required to grant your request, however, if we do, the restriction will be obligatory to us. Our posted privacy policy provides more detailed information about the usage and disclosure of your protected health information. You have the right to review our posted privacy policy before you sign this consent. We reserve the right to amend the terms of our Posted Privacy Policy. You may obtain a copy of the current policy by asking the front office staff or by calling (909) 624-9087.
Acknowledgement of Receipt of Privacy Practice Notice I acknowledge that I have received a Notice of Privacy Practices from Cunning Dental Group.
Signature of Patient or Legal Representative:
Date:
Insurance Release Form I hereby instruct and direct my insurance company to pay Cunning Dental Group by check made out and mailed to: Ronald Cunning DDS Inc., dba Cunning Dental Group, 9595 Central Ave, Montclair, CA 91763. If my current policy prohibits direct payment to the doctor, I hereby also instruct and direct my insurer to make out the check to me and mail it to the address listed above for the professional or dental expense benefits allowable and otherwise payable to me under my current insurance policy as payment toward the total charges for the professional services rendered. THIS IS A DIRECT ASSIGNMENT OF MY RIGHTS AND BENEFITS UNDER THIS POLICY. This payment will not exceed my indebtedness to the above-mentioned assignee. I have agreed to pay in a current manner any balance of said professional service charges over and above this insurance payment. A photocopy of this assignment shall be considered as effective and valid as the original. I also authorize the release of any information pertinent to my case to any insurance company, adjuster or attorney involved in this case.
Signature of Patient or Legal Representative:
Date:
Cunning Dental Group (877)41-SMILE HIPAA/INSURANCE RELEASE/ NOTICE OF PATIENT RESPONSIBILITY 0719 Page 1 of 2
Notice of Patient Responsibility I understand that I am personally responsible for the cost of my dental care. I agree to pay for any dental work rendered by the office, if for any reason whatsoever my insurance coverage denies liability. I will notify this office of any changes in my eligibility for insurance coverage. I understand that should my account become delinquent and require collection efforts, I will be responsible for any collection fees and reasonable attorney costs.
Examination Cancellation Policy In order to better serve all of our patients, if you cancel or otherwise do not show for your reserved time without providing us with a minimum 2 working day notice you will be charged a fee of $71.
Hygiene Cancellation Policy In order to better serve all of our patients, if you cancel or otherwise do not show for your reserved time without providing us with a minimum 2 working day notice you will be charged a fee of $100.
Treatment Cancellation Policy In order to better serve all of our patients, if you cancel or otherwise do not show for your reserved time without providing us with a minimum 2 working day notice you will be charged a fee of $100 per hour of booked treatment time.
Sleep Dentistry Cancellation Policy In order to reserve time for sleep dentistry, you must pay the current sleep dentistry fee of $505, in full, at the time of scheduling. If you cancel or otherwise do not show for this reserved time without providing us with a minimum 2 working day notice your sleep fee will be forfeited.
General Anesthesia Cancellation Policy In order to reserve time and bring in an additional provider for general anesthesia purposes, we ask that you provide us with a minimum 2 working day notice if you are to cancel or reschedule your general anesthesia appointment. Failure to provide us with the minimum 2 working day cancellation notice will result in a fee of $500 per hour of general anesthesia scheduled.
Signature of Patient or Legal Representative:
Printed Name of Patient or Legal Representative:
Date:
Cunning Dental Group (877)41-SMILE HIPAA/INSURANCE RELEASE/ NOTICE OF PATIENT RESPONSIBILITY 0719 Page 2 of 2 Patient Name: Account #: DOB:
HIPAA Privacy Authorization Authorization for Use or Disclosure of Protected Health Information (Required by the Health Insurance Portability and Accountability Act, 45 C.F.R. Parts 160 and 164) If you choose not to have any family member, friend or representative have access to your protected health information you DO NOT need to
I authorize Cunning Dental to use and disclose my protected health information described below to: Full Name Relationship to Patient Phone Number
I authorize my named representative(s) above to receive information regarding my treatments or consultations, billing or claims payments, or other purposes related to my care.
This authorization shall be in force until I inform Cunning Dental in writing, that I would like to revoke the authorization. I understand that my cancellation must be in writing, signed by me or on my behalf, and it will only be effective when Cunning Dental actually receives it. I understand that a revocation is not effective to the extent that any person or entity has already acted in reliance on my authorization or if my authorization was obtained as a condition of obtaining insurance coverage and the insurer has a legal right to consent a claim.
I understand that my treatment, payment, enrollment, or eligibility for benefits will not be conditioned on whether or not I sign this authorization.
I understand that information used or disclosed pursuant to this authorization may be disclosed by the recipient and may no longer be protected by federal or state law.
Signature of Patient or Legal Representative:
Printed Name of Patient or Legal Representative:
Date:
Cunning Dental Group (877)41-SMILE HIPAA Privacy Authorization 0719 Page 1 of 1 Patient Name: Account #: DOB:
ORAL CANCER SCREENING CONSENT FORM
The incidence of oral cancer continues to rise in the USA and one American dies every hour of every day from oral cancer complications. Late detection of oral cancer is the main reason that mortality rates are very high and earlier detection of abnormalities can lead to a better chance of survival. Patients with history of tobacco use, chronic alcohol consumption and oral HPV infection are at an increased risk of developing oral cancer.
Traditionally, dentists have done oral cancer screening with the naked eye, but VELscope (Visually Enhanced Lesion scope) will help pinpoint and identify suspicious tissue at earlier stages before they may become life threatening concerns.
VELscope, similar to other early detection procedures like colonoscopy, mammography, PAP smear and PSA exam, is a painless, non-invasive blue light that is shined into the patient’s mouth revealing any abnormalities. The images are viewed through the back of the VELscope handpiece and the dentist may find tissue abnormalities at an earlier stage.
The VELscope testing is in addition to our traditional visual oral cancer screening and will add only a few minutes to the entire exam. The fee for this enhanced examination is $30. As part of our standard of care and because we care about you, we strongly recommend that you choose this additional screening procedure.
Once again, we feel this breakthrough technology is very important to the enhanced quality of care we can offer to our patients and thank you for making a commitment to your dental health and overall health.
☐ YES, I authorize Cunning Dental to perform the VELscope examination. The fee will be $30 which is due now.
☐ NO, I understand the benefits of this screening and choose not to have the VELscope examination.
Patient Signature: Date:
Printed Name:
Cunning Dental Group (877)41-SMILE ORAL CANCER SCREENING - VELSCOPE 0919 Page 1 of 1