<p> PATIENT INFORMATION</p><p>DATE_____/_____/_____</p><p>PATIENT NAME______</p><p>ADDRESS______</p><p>CITY/TOWN______STATE______ZIP______</p><p>HOME PHONE ______-______-______CELL PHONE ______-______-______</p><p>BUSINESS PHONE ______-______-______EMAIL ______</p><p>DATE OF BIRTH ______/______/______SOCIAL SEC. #______-______-______</p><p>MARRIED______SINGLE ______DIVORCED ______WIDOWED ______</p><p>PERSON TO CONTACT IN CASE OF EMERGENCY NAME ______ADDRESS ______PHONE ______-______-______</p><p>ACCOUNT INFORMATION DENTAL INSURANCE PERSON FINANCIALLY RESPONSIBLE PRIMARY INSURANCE FOR ACCOUNT NAME______SUBSCRIBER______</p><p>ADDRESS______INSURANCE COMPANY______</p><p>ADDRESS______DOB ______/______/______GROUP#______</p><p>OCCUPATION______SOCIAL SECURITY #______-______-______</p><p>EMPLOYER______FAMILY DEDUCT______</p><p>EMPLOYER ADDRESS______SECONDARY INSURANCE</p><p>______SUBSCRIBER______</p><p>BUSINESS PHONE ______-______-______INSURANCE COMPANY______</p><p>SOCIAL SECURITY #______-______-______ADDRESS______GROUP#______WHO REFERRED YOU TO OUR OFFICE SOCIAL SECURITY #______-______-______</p><p>NAME______FAMILY DEDUCT______</p><p>1 DENTAL HISTORY</p><p>1. DATE OF LAST DENTIST VISIT ______</p><p>2. REASON FOR LAST VISIT ______</p><p>3. LAST FULL SET OF X-RAYS______If within last year can we request a copy of X-rays? Yes______No ______Name______Address______Tel # ______-______-______4. DO YOUR GUMS BLEED? On brushing______Eating______Flossing______Spontaneously______</p><p>5. ARE YOUR TEETH SENSITIVE TO… Hot______Cold______Pressure______Sweets______</p><p>6. ANY COMPLICATIONS DURING OR FOLLOWING DENTAL TREATMENT? If yes, describe______Yes______No______</p><p>7. DO YOU GRIND YOUR TEETH, CLENCH YOUR JAWS OR HAVE PAIN OR CLICKING IN THE JOINT NEAR YOUR EARS? Yes______No______</p><p>8. ANY SORES OR GROWTHS IN YOUR MOUTH? Yes______No______Where?______How Long? ______</p><p>9. HAVE YOU HAD PREVIOUS ORTHODONTIC TREATMENT? Yes______No______When?______Dr.______</p><p>10. HAVE YOU EVER BEEN TOLD YOU HAD PERIODONTAL DISEASE? Yes______No______</p><p>11. DO YOU PREFER… Novocaine______Nitrous Oxide______Both ______Neither ______</p><p>12. ARE YOU HAPPY WITH THE APPEARANCE OF YOUR TEETH? Yes______No______</p><p>13. DO YOU HAVE ANY DISCOLORED TEETH THAT BOTHER YOU? Yes______No______</p><p>14. ANY TEETH THAT BOTHER YOU IN GENERAL? Where?______Yes______No______</p><p>15. ANY ADDITIONAL INFORMATION YOU FEEL MAY BE HELPFUL IN YOUR DENTAL TREATMENT? Yes______No______</p><p>Patient Signature______Date______/______/______</p><p>2 MEDICAL HISTORY Answers to the following questions are for our records only and will be considered confidential. Your cooperation in providing ACCURATE INFORMATION is necessary. INCORRECT INFORMATION CAN BE DANGEROUS TO YOUR HEALTH.</p><p>1. ARE YOU IN GOOD HEALTH: Yes______No______If no, explain.______</p><p>2. ANY CHANGES IN YOUR GENERAL HEALTH IN THE PAST YEAR? Yes______No______</p><p>3. HAVE YOU BEEN IN A HOSPITAL FOR ANY REASON? Yes______No______</p><p>4. HAVE YOU BEEN OR ARE YOU UNDER THE CARE OF A PHYSICIAN FOR ANY REASON? Yes______No______</p><p>5. ARE YOU TAKING ANY MEDICATIONS, DRUGS OR PILLS? Yes______No______If yes, please list: MEDICATION REASON MEDICATION REASON 1. FOR 6. FOR 2. FOR 7. FOR 3. FOR 8. FOR 4. FOR 9. FOR</p><p>6. CURRENT TOBACCO USE Yes___No____ 7. CURRENT ALCOHOL USE Yes___No____ # Per Day______# Years______NO USE NO USE CIGARRETTES LESS THAN 8 DRINKS PER WEEK CIGARS 8-21 DRINKS PER WEEK PIPE MORE THAN 21 DRINKS PER WEEK CHEWING TOBACCO</p><p>8. ARE YOU ALLERGIC OR HAVE YOU REACTED ADVERSELY TO ANY MEDICATION? PLEASE CIRCLE. Yes______No______PAIN KILLERS (ASPRIN, CODEINE, DEMEROL ETC.) NITROUS OXIDE LOCAL ANESTHETIC (NOVOCAINE) ANTIBIOTICS (PENICILLIN, ERYTHROMYCIN, ETC.)</p><p>9. ARE YOU ALLERGIC TO ANY OTHER MEDICATION OR SUBSTANCE? Yes______No______</p><p>10. DO YOU USE COCAINE? Yes______No______THE USE OF DENTAL ANESTHETICS INCREASES THE BODY REACTION TO COCAINE AND A PATIENT COULD EXPERIENCE DISTRESS, HEART ATTACK, CORONARY SPASM, LUNG DAMAGE, AND DEATH.</p><p>11. ARE YOU PREGNANT? Due Date______Yes______No______</p><p>12. ARE YOU ON BIRTH CONTROL PILLS? Yes______No______ORAL CONTRACEPTIVES CONTAINING ESTROGEN MAY NOT WORK 3 WELL IF YOU ARE TAKING PENICILLIN, AMPICILLIN, OR PENICILLIN V. UNPLANNED PREGNANCIES MAY OCCUR. USE ALTERNATE MEANS OF BIRTH CONTROL WHILE TAKING THESE PENICILLINS.</p><p>MEDICAL HISTORY</p><p>13. CIRCLE ANY OF THE FOLLOWING WHICH YOU HAVE HAD OR PRESENTLY HAVE NONE APPLY______</p><p>Heart Failure Hepatitis A AIDS Heart Surgery Hepatitis B HIV positive Heart disease Hepatitis C Venereal Disease Heart Attack Liver Disease Syphilis, Gonorrhea Heart Stents Jaundice Herpes Congenital Heart Problems Diabetes Glaucoma Mitral Valve Prolapse Tuberculosis TB Arthritis Pacemaker Asthma Rheumatism Artificial Heart Valve Breathing Problems Drug Addiction Rheumatic Fever Hay Fever Convulsions Scarlet Fever Thyroid Disease Epilepsy Stroke Cancer Cold Sores Excessive Bleeding Radiation Treatment Anemia Psychiatric Treatment Chemotherapy Sickle Cell Disease Kidney Disease Tumor or Growth Renal Dialysis</p><p>14. DO YOU HAVE ANY DISEASE OR PROBLEM NOT LISTED? Yes______No______If yes, please specify.______</p><p>15. NAME OF PHYSCIAN______</p><p>Address______</p><p>Date or Last Visit______</p><p>Reason for Last Visit______</p><p>16. IN CASE OF EMERGENCY, NOTIFY:</p><p>Name______</p><p>Relation______</p><p>Telephone #______</p><p>I ACKNOWLEDGE THAT THE ABOVE INFORMATION IS TRUE.</p><p>Patient Name (Print)______</p><p>4 Patient Signature______Date ______/______/______</p><p>HEALTH CARE PRIVACY</p><p>I, ______give complete and unrestricted authorization and durable Power of Attorney to my designated agent(s) for the following: All information concerning my health care including the following: Treatment, Insurance Disclosures, All Doctor’s Fees, To Be Present During Examinations, Tests, Doctor’s Consultations, Doctor’s Reports, Hospital Reports, Medications Given or Prescribed, Procedures Needed, Lab Results, MRI, Sonogram, Cat Scan Results, Any Other Health Care Information.</p><p>We may use or disclose Protected Health Information about you to a relative, care giver or to any other person identified by you when you are present. We may also disclose PHI to those who are involved in helping to pay for your care.</p><p>DETERMINATION OF HEALTH CARE AGENTS</p><p>I, (insert your name) ______</p><p>Appoint (name) ______</p><p>Address ______</p><p>Phone ______</p><p>As my agent to make any and all health care decisions for me, except to the extent I state otherwise in this document. (If the agent designated is your spouse, the designation is automatically revoked by law if your marriage is dissolved.)</p><p>LIMITATIONS ON THE DECISION MAKING AUTHORITY OF MY AGENT ARE AS FOLLOWS: ______</p><p>______</p><p>If the person designated as my agent is unable or unwilling to make health care decisions for me, I designate the following persons to serve as my agent to make health care decisions for me as authorized by this document, who serve in the following order:</p><p>FIRST ALTERNATIVE AGENT Name ______</p><p>Address ______Phone ______</p><p>SECOND ALTERNATIVE AGENT 5 Name ______</p><p>Address ______Phone______</p><p>Signature______Date______/______/______</p><p>FINANCIAL RESPONSIBILITY GUIDELINES</p><p>We are pleased that you have chosen us for your care and promise to do our best to provide you with the best care possible. We wish to make your visit with our office as pleasant as possible and sincerely hope that you will be satisfied with the care you receive here.</p><p>Previous events have forced us to institute the following policies. Please read them carefully and sign in the space provided below. Be certain to ask if there is anything you do not understand.</p><p>1. We are happy to provide a billing service and courtesy of claim submission to numerous insurance carriers, however, we must remind you that you are also responsible to make sure that your bill is paid. Your insurance policy is an arrangement between you and your insurance carrier.</p><p>2. Accounts requiring additional statements due to excessive lateness are subject to a $5.00 billing charge per month. If an account is turned over for collection, a collection fee will also be added.</p><p>3. If your insurance carrier requires a referral to be seen in our office, you are responsible to make sure that you have a valid referral for each visit.</p><p>4. You are responsible for all co-payment, deductibles, and coinsurance amounts as indicated by your insurance carrier. For more extensive dental work, we require a portion of the fees to be paid up front on the initial date of service.</p><p>5. If YOU receive the insurance payment for our service, we expect you to assign that check over to us immediately, even if you have not yet received a bill from us.</p><p>6. If you cannot keep an appointment, you must contact us and cancel at least 24 hours in advance, unless of course, in an emergency. If you fail to contact us to cancel the appointment, there may be a fee for an office visit, which will not be covered by your insurance.</p><p>7. To cover costs for any check returned for insufficient funds, there will be a $25 fee added to the patient’s account.</p><p>Thank you for your understanding and cooperation. Please sign below.</p><p>6 ______Date______Signature </p><p>Dr. Anthony V. Sforza, D.M.D. 76 East Main Street, Suite #4 Huntington, NY 11743 631-271-4747</p><p>Patient Acknowledgement</p><p>I hereby acknowledge that I have been given the opportunity and the right to read and ask questions regarding the Notice of Privacy Practices. I understand that the notice may change as needed and I will be given a revised copy at my request.</p><p>______Patient Name (Please Print)</p><p>______Patient Signature</p><p>______7 Date</p><p>8</p>