test form only - Brownstone Dental

    Treatment Plan

    Medical HistoryAllergy Alert

    Patient Information:

    Today's Date:

    Male:

    Female:

    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.

    Patients or Responsible Party’s Signature:

    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.

    SIGNATURE OF PATIENT, PARENT OR GUARDIAN:

    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).

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

    Name:

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

    Signature:

    (Signature of Patient or Patient's Representative)

    Witnessed by:

    (Print Name)

    Signature:

    (Signature of Witness)

    HIPAA FORM


    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

    Signature

    Date

    FOR OFFICE USE ONLY

    We have made every effort to obtain written acknowledgment of receipt of our Notice of Privacy from this patient but it could not be obtained because:

    The patient refused to sign.Due to an emergency situation.Weren’t able to communicate with the patient.Other (Please provide specific details)




    Employee Signature

    Date

    HIPAA FORM


    Patient's Name:

    DOB:

    Date:

    Please read and initial the items checked below and read and sign at the bottom of form.

    1. EXAM AND X-RAYS
    2. DRUGS AND MEDICATIONS
    3. I understand that antibiotics and analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction).

    4. CHANGES IN TREATMENT PLAN
    5. I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give my permission to the Dentist to make any/all changes and additions as necessary

    6. FILLINGS
    7. I understand that care must be exercised in chewing on fillings especially during the first 24 hours to avoid breakage. I understand that a more expensive filling that initially diagnosed may be required due to additional decay. I understand that significant sensitivity is a common after effect of a newly placed filing.

    8. REMOVAL OF TEETH
    9. Alternatives to removal have been explained to me (root canal therapy, crowns, and periodontal surgery, etc.) and I authorize the Dentist to remove the following teeth and any others necessary for reasons in paragraph #3. I understand removing teeth does not always remove all the infection, if present, ‘and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some o which are paint swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time (days or months) or fractured jaw. I understand I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility

    10. CROWNS, BRIDGES AND CAPS
    11. I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realize the final opportunity to make changes in my new crown, bridge, or cap (including shape, fit, size and color) will be before cementation.

    12. DENTURES, COMPLETE OR PARTIAL
    13. I realize that full or partial dentures are artificial, constructed of plastic. metal. and/or porcelain. The problems of wearing these appliances have been explained to me, including looseness, soreness, and possible breakage. I realize the final opportunity to make changes in my new dentures (including shape, fit, size, placement, and color) will be the •teeth in wax" try-in visit. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in the initial denture fee. I also understand the wearing of dentures is difficult. Sore spots altered speech and difficulty in eating are common problems. Immediate dentures (placement of dentures immediately after extractions) may be painful. Immediate dentures may require considerable adjusting anc several relines. A permanent reline will be needed later. This is not included in the denture fee. J understand that it is my responsibility to return for delivery of the dentures. I understand that failure to keep my delivery appointment may result in poorly fixed dentures. If a remake is required due to my delays of more than 30 days there will be additional charges.

    14. ENDODONTIC TREATMENT (ROOT CANAL)
    15. I realize there is no guarantee that root canal treatment will save my tooth, and that complications can occur from the treatment, and that occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily affect the success of the treatment, I understand that occasionally additional surgical procedures may be necessary following root canal treatment (apicoectomy).

    16. PERIODONTAL LOSS (TISSUE & BONE)
    17. I understand that care must be exercised in chewing on fillings especially during the first 24 months to avoid breakage. I understand that a more expensive filling that initially diagnosed may be required due to additional decay. I understand that significant sensitivity is a common after effect of a newly placed filling.

      I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authorized. I have had the opportunity to read this form and ask questions. My questions have been answered to my satisfaction. I consent to the proposed treatment.

    Signature of Patient:

    Date:

    Signature of Parents/Guardian if patient is minor:

    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

    Signature of Patient:

    Date