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Key West Dental Associates

3146 Northside Drive Key West, Florida 33040

305-293-9490

Patient Information And Medical History

First Name:
MI:
Last Name:
Patient is:

Patient Information

Address:
City:
State:
Zip:
Pager:
Home Phone:
Work Phone:
Ext:
Cellular:
Sex:
Marital Status:
Birth Date:
Age:
Soc. Sec:
Drivers Lic:
E‐mail:

DENTAL INSURANCE INFORMATION

* We do not accept Medicaid/Medicare/Discount Plans

Name of Insured:
Relationship to Patient:
Member ID:
Group Number:
Insured Birth Date:
Employer:
Address:
City:
State:
Zip:
Insurance Company:
Provider Services Phone Number:
Address:
City:
State:
Zip:

Patient's Signature

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Date:

Guardian's Signature

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Date:


Medical History:

Please answer all questions. Answers to the following questions are for our records only and will be considered confidential.

Are you in good health?
Height:
Weight:
Has there been any change in your general health?
Your last physical examination was on:
Are you now under the care of a physician?
Name of your physician:
Address of your physician:
Have you ever had a serious illness or operation?
Have you been hospitalized with any of the following within the last 5 years?
Do you have a persistent cough or cough up blood?
Low/High blood pressure(circle one)
Venereal Disease
AIDS or HIV+
Other:
Have you had abnormal bleeding associated with previous extractions, surgery, or trauma?
Do you bruise easily?
Have you ever required a blood transfusion
If yes, explain the circumstances:
Do you have any blood disorder such as anemia?
Have you had surgery or x‐ray treatment for a tumor, growth or other condition of your mouth or lips?

Medications

Preferred Pharmacy Name:
Preferred Pharmacy Phone:
Preferred Pharmacy Address:
Are you taking any drug or medication?
If yes, what?
Are you taking any of the following?
Antibiotics or sulfa drugs
Tranquilizers
Cortisone (steroids)
Medicine for high blood pressure
Insulin, Tolbutamide (Orinase) or similar drug
Digitalis or drugs for heart trouble
Osteoporosis Drugs (Fosamax, Aredia, Zometa etc.)
Aspirin
Anticoagulants (blood thinners such as Coumadin, Plavix etc)
Nitroglycerin
Any natural product, herbal supplement or homeopathic remedy?
Chemotherapy Drugs
Fen‐Phen (now or in the past) or related drug such as Ionimin, Adipex, Phentermine, Fastin, Pondimin (Fenfluramine), and Redux (dexfenfluramine)
Oral Contraceptives
If yes, what are you using?
Other:

Habits:

Do you smoke?
If yes, how much?
Do you drink alcoholic beverages?
Do you take any recreational drugs?

Do you have any of the following?:

Cardiac pacemaker
A removable dental appliance
Implants/Artificial prosthesis (Knee joints, elbow pins etc)

Do you have, or have you had, any of the following diseases or problems?:

Rheumatic fever or rheumatic heart disease
Hepatitis, jaundice, or liver disease
Heart Murmur or mitral valve prolapse
Congenital heart lesions
Convulsions/epilepsy
Stroke
Asthma or hay fever
Hives or skin rash
Fainting spells or seizures
Arthritis
Inflammatory rheumatism (painful, swollen joints)
Stomach ulcers
Kidney trouble
Tuberculosis
A tumor or growth
Radiation therapy or chemotherapy
Thyroid trouble
Bleeding tendency /abnormal bleeding
Are you immunosuppressed? Possibly from transplant surgery
Cardiovascular disease (heart trouble, heart attack, coronary occlusion, high blood pressure, arteriosclerosis, stroke)
Do you have pain in the chest upon exertion?
Are you ever short of breath after mild exercise?
Do you get short of breath when you lie down or do you require extra pillows when you sleep?
Diabetes
Do you have to urinate (pass water) more than six (6) times a day?
Are you thirsty much of the time?
Does your mouth frequently become dry?

Allergy:

Are you allergic or have you reacted adversely to:
Local anesthetic
Barbiturates, sedatives, or sleeping pills
Sulfa Drugs
Codeine
Valium or other tranquilizer
Aspirin
Iodine
Latex
Penicillin or other antibiotics (such as amoxicillin, clindamycin, erythromycin, Keflex etc)
Other:
Have you had any serious trouble associated with previous dental treatment?
If yes, explain:

For Women Only:

Are you pregnant or could you be?
If yes, when are you due?
Are you nursing?
Are you taking oral contraceptives?
If yes, what?
Comments:

I certify to the best of my knowledge that the above information is correct and that if there are any changes in the above, I agree to notify my dentist or my surgeon before my next visit.

Patient's Signature:

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Date:

Guardian's Signature:

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Name:
Date:

Doctor's Signature:

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Name:
Date:

 

Financial Policy

There will be a 3% fee added to any credit or debit card payments. We gladly accept cash or check to avoid the fee.

Payment in full (or estimated portion after insurance) is due at the time services are rendered, unless arrangements have been made prior to your appointment.

We accept cash, check, and all major credit cards. We also offer an In-Office Savings Plan (please inquire) and Care Credit, if a payment arrangement is needed.

Any adult accompanying a minor, and his/her parents (or guardian) must provide payment at the time of service.

Initial:

 

Regarding Insurance

Your insurance policy is a contract between you and your insurance company. You are responsible for knowing which dentists participate with your insurance company. Although we make every effort to verify your benefits and coverage accurately, you are responsible for knowing which procedures may or may not be considered for payment by insurance. We will not become involved in disputes between you and your insurance company regarding deductibles, copayments, U&C charges, etc. other than to supply factual information approved by HIPAA policies. You are responsible for any charges not paid by your insurance company within 60 days.

Our office will only file claims to your primary insurance company. If you have a secondary policy, it is your responsibility to file the claim. You will be charged according to your primary benefits schedule.

I understand and agree that (regardless of insurance), I am ultimately responsible for the balance of my account for any dental services rendered.

Initial:

 

Regarding Cancellation and Missed Appointment

Please note, your appointment time is reserved just for you. A late cancellation or missed appointment leaves a hole in our schedule that could have been filled by another patient. As such, we require 24 hours notice for any cancellations or changes to your appointment. Patients who provide less than 24 hours notice, or miss their appointment, are subject to a cancellation fee.

I Understand and Accept
Initial:

 

Photographic Release

As part of certain treatment, we may be taking photographs. These photographs may be used in the following ways:

  1. In-office presentations or academic conference presentations
  2. Promotional materials
  3. Website "Before & After" Cases

By initialing, I am providing permission for Key West Dental Associates to take my photograph and all photos remain the sole property of Key West Dental Associates. (Optional)

Initial:

Patient Signature

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Print Name:
Date:

 

HIPAA Privacy Policy

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that signing this consent I authorize you to use and disclose my protected health infonnation to carry out the following:

  • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
  • Obtaining payment from third party payers (e.g. my insurance company)
  • The day-to-day healthcare operations of our practice.

I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and healthcare operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent in writing at any time. However any use or disclosure that occurred prior to the date I revoke this consent is not affected.

Signed this on:

Patient Signature

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Patient Name:
If signing for a minor relationship:

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