New Patient Forms - Brownstone Dental

    Date:
    Appointment:
    Arrived:
    Walk-In:
    Name:
    Address:
    APT#:
    City:
    State:
    Zip Code:
    Home Phone:
    Business Phone:
    Date of Birth:
    Social Security:
    Exam Date:
    Exam by Dr. Medical HistoryAllergy Alert


    Patient Information:

    Today's Date:

    Gender:

    MaleFemale

    Name:

    DOB:

    Address:

    Apt:

    City:

    State:

    Zip Code:

    Home Phone#:

    Work Phone:

    Cell Phone#:

    Email Address:

    Social Security:

    Person to contact in case of emergency:

    Responsible Information:

    Name:

    Relationship to Patient:

    Address:

    City:

    State:

    (If Diffrent From Above)

    Home Phone#:

    Work Phone:

    Social Security:

    DOB:

    Insurance Information:

    Employee Name:

    Employer Name:

    Insurance Company:

    Group Number:

    Insurance Company Phone#:

    Fax#:

    Employee DOB:

    Employee Social Security #:

    Referred By:

    Whom may we thank for referring you to our office?

    Would you like to receive email and text alert for future appt?

    I hereby authorize doctor or designated staff to take x-rays, study models, photographs and any other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (patient's name)' s dental needs. Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required providing proper care. I agree to the use of anesthetic, sedatives and other medications as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

    Lastly, I agree to be responsible for payments of all services rendered on my behalf or my dependents. I agree that I shall be responsible for any and all expenses incurred at this office, and I understand that payment is due at the time of service unless other arrangements have been made, regardless if I have insurance.

    Date


    Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking could have important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

    Women are you -

    Pregnant/Trying to get pregnant?

    YesNo

    Taking Oral Contraceptives?

    YesNo

    Have you ever had any of the following disetases or medical problems?

    Abnormal Bleeding YesNo
    Alcohol/Drug Abuse YesNo
    Anemia YesNo
    Arthritis YesNo
    Artificial Heart Valves YesNo
    Artificial Joints YesNo
    Asthma YesNo
    Blood Disease YesNo
    Blood Transfusion YesNo
    Cancer YesNo
    Chemotherapy YesNo
    Circulatory Problems YesNo
    Congenital Heart Defect YesNo
    Cortisone Treatments YesNo
    Cough-Persistent or Blood YesNo
    Diabetes YesNo
    Difficulty Breathing YesNo
    Emphysema YesNo
    Epilepsy YesNo
    Fainting Spell YesNo
    Freqeunt Headaches YesNo
    Glaucoma YesNo
    Heart Attack YesNo
    Heart Murmur YesNo
    Heart Surgery YesNo
    Hemophilia YesNo
    Hepatitis, Type YesNo
    Herpes/Fever Blisters YesNo
    High Blood Pressure YesNo
    HIV+AIDS YesNo
    Kidney Problems YesNo
    Liver Disease YesNo
    Low Blood Pressure YesNo
    Mitral Valve Prolapsed YesNo
    Pacemaker YesNo
    Psychiatric Problems YesNo
    Radiation Treatment YesNo
    Rheumatic Fever YesNo
    Scarlet Fever YesNo
    Seizures YesNo
    Shingles YesNo
    Sickle Cell Disease YesNo
    Sinus Problem YesNo
    Stroke YesNo
    Thyroid Problem YesNo
    Tuberculosis YesNo
    Ulcers YesNo
    Venereal Disease YesNo

    Please explain any "Yes" answers:

    Please list any medications you take including over the counter drugs:

    Are you allergic to:

    Penicillia ErythromycTetracyclineCodeineSulfAspirirLateDental Anesthetics

    Other:

    Pharmacy:

    Dental History:

    Why have you come to the dentist today?

    Do you require antibiotic pre-medication prior to dental treatment?

    YesNo

    If yes, why?

    Are you currently in pain?

    YesNo

    Have you had a previous bad dental experience?

    YesNo

    Are you apprehensive about dental treatment?

    YesNo

    Do you or have you ever experienced pain/discomfort in your jaw join (TMJ/TMD)?

    YesNo

    Do your gums ever bleed?

    YesNo

    Privacy & Security Policy:

    Brownstone Dental recognizes the importance of protecting the privacy of all information provided by our customers. Keeping customer information secure, and using it only as our customers want us to, is a top priority for all of us at Brownstone Dental. This is our promise to our individual customers. We will take all reasonable steps to safeguard any information our customers share with us. We will permit only authorized Brownstone Dental employees, who are trained in the proper handling of customer information to have access to that information. Employees who violate our Privacy Policy are subject to disciplinary action including termination. We will not reveal customer information to any external organization unless we have previously informed the customer in disclosures or agreements that are required by law, and have been authorized by the customer

    To the best of m knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health, It is my responsibility to inform the dental office of any changes in medical status.

    Date:


    COMMUNICATION RELEASE FORM

    Date:

    I (insert name of Patient or Patient’s Representative) want Brownstone Dental to communicate with me via e-mail, phone, text, mail or other media about products or services that pertain to my conditions or that can contribute to matters related to my health and lor my medical treatment. I understand my Protected Health Information may be referenced to determine that I may be a likely candidate for products or services that my dental health practitioner may share with me.

    Brownstone Dental may communicate with me about my oral health, treatment appointments, and post-operative follow-ups by mail, e-mail, text or by phone to the contact information on file. it is my responsibility to ensure all my contact information is up-to-date.

    I understand that communication between Brownstone Dental and I may not be encrypted and my information could be intercepted by unauthorized persons. I agree to hold Brownstone Dental harmless for any actions resulting from intercepted communications.

    Brownstone Dental will not be responsible for any unauthorized interceptions. However, we will make reasonable measures to ensure proper delivery or notification of our patient's information. Examples include, but are not limited to, post-operative phone calls and appointment reminders.

    This consent remains in effect until expressly revoked (in writing).

    Name:

    (Print Patient's Name or Name of Patient's Representative)

    Witnessed by:

    (Print Name)


    ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

    Notice to Patient:

    We are required to provide you with a copy of our Notice of Privacy Practices, which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement, if you wish.

    I acknowledge that I have received a copy of this office's Notice of Privacy Practices.

    Print Your Name Here

    Date:



    9824 Fondren Rd.

    Houston, TX, 77096

    Ph: (713)271-3000

    Fax: (713)271-3000

    Welcome to Brownstone Dental,

    We always strive to provide patients with quality dental work, at inexpensive prices. Because of this we provide with complimentary insurance verification. The quote given by your insurance are assumed percentages.

    It is possible that although Brownstone Dental files your claim(s) your insurance provider can deny your claim due to clauses in your insurance coverage, employment, or frequencies in your plan. Brownstone Dental will always strive to have your claims approved. In the event that Brownstone Dental is unable to receive payment from your insurance, the remaining balance that was not paid by the dental insurance provider will be your sole responsibility

    Thank you for trusting us with all your dental needs, Brownstone Dental looks forward to being your permanent dental home!

    Brownstone Dental

    Dr. Shere

    Date: