Forms - Dentist Cosmetic Dentist NY Masci & Hale Orange Ulster Hudson Valley

Step 1

Patient Information

First Name

Please provide a first name.

Last Name

Please provide a last name.

Preferred Name

Please provide a preferred name.

Date of Birth

Please provide a birth date.

Gender

Female

Male

Please provide a gender.

SS#

Only required if designated by your insurance co

Address Street

Please provide an address street.

Apt #

City

Please provide a city.

State

Please provide a state.

Zip

Please provide a zip.

Contact #'s: Home

Please provide a contact home.

Work

Please provide a contact work.

Cell

Please provide a contact cell.

Please provide a contact email.

Finanncial Information

Insurance Plan:

Please have your Insurance Benefits Card available for verification

Employer:

Plan Holder (if other than self)

Date of Birth

SS/ID #:

Relationship to patient:

Aesthetics

Are you happy with the appearance of your teeth?

Would you like your teeth to look whiter?

Would you like to see your smile look different?

Do you like the shape of your teeth?

Are you happy with the appearance of your lips?

Do you have discolored teeth that bother you?

Are you here for a specific reason?

Step 4

PATIENT HIPAA AWARENESS

With my permission, Drs. Masci & Hale may use and disclose protected health information (PHI) about me to carry out treatment, payment and healthcare operations (TPO). Please refer to Drs. Masci & Hale's Notice of Privacy Practice for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Drs. Masci & Hale reserve the right to revise its Notice of Privacy Practices at anytime. A revised Notice of Privacy Practices may be obtained by forwarding a written request to the Privacy Officer.

With my permission, the office of Drs. Masci & Hale may call my home or other designated locations and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out TPO, such as appointment reminders, insurance items and any call pertaining to my clinical care, including laboratory results among others.

With my permission, the office of Drs. Masci & Hale may mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements as long as they are marked "Personal and/or Confidential."

With my permission, the office of Drs. Masci & Hale may e-mail to my home or other designated location any items that assist the practice in carrying out TPO, such as appointment reminder cards and patient statements. I have the right to request that Drs. Masci & Hale restrict how it uses or discloses my PHI to carry out TPO. However, the practice is not required to agree to my requested restrictions, but if it does, it is bound by this agreement.

By signing this, I am allowing Drs. Masci & Hale to use and disclose my PHI for TPO.

I may revoke my consent in writing except to the extent that the practice has already made disclosures in reliance upon my prior consent.

Step 5

Financial Responsibility Awareness

Masci & Hale Advanced Aesthetic and Restorative Dentistry is a Fee for Service, Out of Network (non-insurance participating) Practice. This means that we are not contracted with any dental insurance companies and do not accept insurance payments as full coverage for procedures. We will do all the necessary paperwork & claim submissions for you.

As a courtesy to our patients with insurance plans that are willing to send our office their payment directly, we will accept that insurance check as the initial payment and then bill our patient for any remaining balance. If they cover our fee in full, you will not be billed for any balance.

A credit card can be left on file ahead of time for automatic payment of any out of pocket balances.

There are some insurance companies that will not send us their payment directly. They will however reimburse the patient if it's a PPO policy. For patients with these plans, you will be responsible for full fees at time of service unless other payment arrangements have been agreed upon.

By signing below, you agree that you fully understand our office financial policy and are aware that you will be responsible for any/all fees remaining after your insurance has paid their allowable portion.

Step 6

Summary

Patient Information

First Name:

Last Name:

Preferred Name:

Date of Birth:

Gender:

SS# :

Address Street:

Apt #:

City:

State:

Zip:

Contact #'s: Home:

Work:

Cell:

Email:

Finanncial Information

Insurance Plan:

Please have your Insurance Benefits Card available for verification

Employer:

Plan Holder (if other than self)

Date of Birth:

SS/ID #:

Relationship to patient:

Aesthetics

Are you happy with the appearance of your teeth?

Would you like your teeth to look whiter?

Would you like to see your smile look different?

Do you like the shape of your teeth?

Are you happy with the appearance of your lips?

Do you have discolored teeth that bother you?

Are you here for a specific reason?

Medical Info

1) Are you in good health?

2) Has there been any change in your general health within the past year?

3) Are you now under the care of a physician?

If so, what is the condition being treated?

Physician's Name

Address

City

State:

Zip:

Phone:

4) Date of last physical examination

5) Are you taking medicines, including non-prescription medicine?

If yes, what medicine?

Women Only

6) Are you pregnant?

7) Nursing?

8) Taking birth control pills?

Conditions Do you have any of the following diseases or problems?

9) Abnormal bleeding

10) AIDS or HIV

11) Anemia

12) Arthritis

13) Rheumatoid arthritis

14) Asthma

15) Blood transfusion If yes, date

16) Cancer/chemotherapy/radiation treatment

17) Cardiovascular disease

18) Angina

19) Arteriosclerosis

20) Artificial heart valves

21) Coronary insufficiency

22) Coronary occlusion

23) Damagead heart valves

24) Heart attack

25) High blood pressure

26) Inborn heart defects

27) Mitral valve prolapse

28) Pacemaker

29) Chest pain upon exertion

30) Chronic pain

31) Persistent diarrhea

32) Disease, drug or radiation-infection induced immunosurpression

33) Diabetes, if yes, specify

Type I

Type II

34) Dry mouth

35) Eating disorder Specify

36) Epilepsy

37) Fainting spells or seizures

38) G.F. reflux

39) Glaucoma

40) Hemophilia

41) Hepatitis, jaundice or liver disease

42) Recurrent infections Specify

43) Kidney problems

44) Low blood pressure

45) Mental health disorders Specify

46) Migraines

47) Night sweats

48) Neurological disorders Specify

49) Osteoporosis

50) Persistent swollen glands in neck

51) Repiratory problems

If yes,specify

Emphysema

Bronchitis

52) Severe headaches

53) Severe or rapid weight loss

54) Sexually transmitted disease

55) Sinus trouble

56) Sleep disorder

57) Sores or ulcers in the mouth

58) Stroke

59) Systemic lupus erythematosus

60) Thyroid problems

61) Tuberculosis

62) Ulcers

63) Excessive urination

64) Any other diseases, condition or problem not listed above? Please explain:

65) Has a physician or previus dentist recommended that you take antibiotics prior to your dental treatment?

If so, what antibiotic and dose?

Name of physician or dentist:

Phone:

66) Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?

If so, when was this operation done?

67) If yes. Have you had any, complications or difficulties with your prosthetic joint?

Allergies Are you allergic or have you had a reaction to:

68) Local anesthetics

69) Aspirin

70) Penicilin or other antibiotics

71) Barbiturates, sedatives or sleeping pills

72) Sulfa drugs

73) Codeine or other narcotics

74) Latex

75) Lodine

76) Hay fever/seasonal

77) Animals

78) Food (specify)

79) Other (specify)

If yes responses, specify type or reaction

Signature

Step 1

Patient Information

Finanncial Information

Aesthetics

Step 2

Medical Information

Patient Information

Medical Info

Conditions Do you have any of the following diseases or problems?

Step 3

Medical Information

Conditions

Allergies Are you allergic or have you had a reaction to:

Signatures

Step 4

PATIENT HIPAA AWARENESS

Step 5

Financial Responsibility Awareness

Step 6

Summary

Patient Information

Finanncial Information

Aesthetics

Medical Info

Conditions Do you have any of the following diseases or problems?

Allergies Are you allergic or have you had a reaction to: