Dr. Richard Appleton, DDS, MS

Dr. Richard Appleton, DDS, MS

Registration Form

(Please Print)

Today’s Date:
PATIENT INFORMATION
Mr. / Ms. / Patient Name:
Mrs. / Dr.
Address:
City: / State: / Zip Code:
Phone: / Home: / Work 1: / Preferred Number called:
Cell: / Work 2:
Email:
DOB: / Sex: Male Female / Marital: Single Married Divorced Widowed
Age: / SSN: / Spouse:
Student: No Full Time Part Time / Where:
Referred by: / Dr. / Family/Friend: / Newspaper AD:
Preferred Pharmacy:
DENTAL INSURANCE INFORMATION
(Please give your dental insurance card and driver’s license to the receptionist)
Person responsible for bill: / DOB: / Address (if different): / Home phone no:
Is this patient covered by insurance? Yes No
Please indicate primary insurance:
Subscriber’s name: / Subscriber’s SSN: / Subscriber’s DOB: / Group no: / ID/Member no:
Occupation: / Employer: / Employer address: / Employer phone no:
Patient’s relationship to subscriber: Self Spouse Child Other
Name of secondary insurance (if applicable): / Subscriber’s name: / Group no: / ID/Member no:
Patient’s relationship to subscriber: Self Spouse Child Other
IN CASE OF EMERGENCY
Name of local friend or relative (not living at the same address): / Relationship to patient: / Home phone no:
( ) / Work phone no:
( )
The above information is true to the best of my knowledge. I understand that I am financially responsible for any balance. I also authorize Appleton Prosthodontics or insurance company to release information required to process my claims. I consent to the initial examination and any radiographs (x-rays) that may need to be taken for diagnostic purposes.
Patient/Guardian signature: / Date

MEDICAL DENTAL HISTORY FORM

Patient Name:______/ Medical Clinic:______
Physician:______
Allergies to: / PreMed required? Yes No
Latex: Yes No
List Medication Allergies: / Reason:______
Other: / Type:______Dosage:______

Current Medications (Prescription, over the counter and Herbal)

MEDICATION / DOSAGE / FREQUENCY / MEDICATION / DOSAGE / FREQUENCY

Past and Current Medical Conditions (mark all that apply)

Yes Yes

AIDS/ HIV positive / Hospitalization/ operation(s) in last 5 years
Details:
Alcohol or chemical dependency / Immunological disease
Anemia / Indwelling defibrillator
Artificial heart valves / Kidney disease
Artificial joints / Leukemia
Arthritis or other joint disorder / Lung disease
Asthma / Mitral valve prolapse
Bleeding problems / Neurologic disease
Blood thinners/Aspirin Therapy / Other Autoimmune disease (lupus, pemphilus, etc.)
Cancer / Other Psychiatric disorder
Cerebral Palsy / Osteoporosis
Chemotherapy / Pacemaker
Convulsions / Past use of Fenphen
Depression: diagnosed / Radiation Treatment to head/ neck
Diabetes Type Controlled? Y/N / Rheumatic Fever
Dialysis / Shortness of Breath
Eating Disorder / Sinus Trouble
Emphysema / Sjogrens disease
Epilepsy/ Seizures / Sleep apnea
Fainting/ Dizziness / Stomach: reflux ulcer
Fibromyalgia / Stroke
Glaucoma / Thyroid disease
Headaches / Tuberculosis
Head/ Neck/ Mouth injuries / Under Physician’s care
Heart Murmur / Venereal disease
Heart trouble/ disease / Women: nursing
Heart surgery / Women: oral contraceptive
Hemophilia / Women: pregnant
Hepatitis
High Blood Pressure
History of Organ Transplant

TOBACCO:DO YOU HAVE CONSISTENT PROBLEMS WITH:

Tobacco user? Yes No
Type:
Amount:
Number of years:
Dry mouth/ excessive thirst
Sensitive teeth? Hot/Cold/Pressure/Sweets
Cold sores/ blisters/ oral lesions
Are you aware of any swelling or lumps
Sore/ bleeding gums
Loose teeth
Difficulty chewing
Food catches between teeth
Teeth/ filling break frequently
Clenching or grinding habits
Do you hear popping/clicking/snapping
Do you have jaw pain
Are you nervous about dental work

DENTAL INFORMATION:

Previous Dentist:
Current dentist:
What made you decide to make this dentist appointment?

Dental Consent Form

All patients receiving dental treatment will be asked to sign consent forms. Please review and sign consent before beginning treatment.

State law requires that you be given certain information and that we obtain your consent prior to beginning any treatment. What you are being asked to sign is a confirmation that we will discuss the nature and purpose of the treatment and the known risk associated with the treatment; that you will be given an opportunity to ask questions and that all questions are answered in a satisfactory manner. Please read this form carefully before signing it and ask about anything that you do not understand. We will be pleased to explain.

CONSENT FOR DENTAL TREATMENT

I hereby authorize Dr. Richard S. Appleton, DDS, MS, with the help of his staff to perform any dental treatment that we have discussed and agreed upon. I trust his expertise and dental knowledge.

IMPORTANCE OF PATIENT COMPLIANCE

I agree and understand that the degree of success of any dental treatment, including maintenance and hygiene, is directly related to my cooperation and that, if I fail to cooperate as requested and instructed, I may suffer temporary or permanent injury to my dental health, general health and/or to the dental work performed by my dentist. I agree to return for my regular scheduled visits as specified by the doctor for follow up checks to assure proper oral health. If evidence of pain, swelling, or inflammation should occur, I agree to notify Dr. Richard S. Appleton, DDS, MS, immediately.

RISK ASSOCIATED WITH NO TREATMENT

I understand that should I not proceed with dental treatment that it may result in further damage to my teeth.

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I hereby state that I have read and fully understand this consent form, that I give my consent for an initial exam and diagnostic procedures that may be needed to determine any further treatment that may be necessary.

Patient Signature: ______Date: ______

Witness: ______

APPLETON PROSTHODONTICS

OFFICE/FINANCIAL POLICY

1. In order that we do not keep you waiting, we reserve your appointment time only for you, and we do not double book appointments. Forty-eight hours (48) notice is required if you need to change an appointment of two (2) hours or less, five (5) days notice is required is to change a surgery appointment or an appointment longer than 2 hours. There is a minimum $150 per hour scheduled charge for cancellation without adequate notice, except in the case of a medical emergency. Patients with two hours or more appointments maybe charged $150 per hour. Any patient that is fifteen (15) minutes late for their scheduled appointment will be asked to reschedule for the next available appointment.

2. Patients are responsible for payment in full five (5) days before treatment begins or making payment arrangements before treatment can begin. If you choose a payment plan a credit check may be made prior to any payment plan authorization. If payments are not made five (5) days prior to treatment, your appointment will be cancelled without notice.

DENTAL INSURANCE POLICY

As a courtesy to you, we will assist you in filing for your insurance benefits. To avoid any confusion, please be aware of the following facts:

1. We are a specialist practice and are not in network.
2. No insurance company will pay for 100% of prosthodontic treatment. Your insurance company may provide some assistance. Each insurance company will pay different amounts depending upon the policy.
3. Some dental insurance companies will not pay for prosthodontic treatment and very few medical policies cover this service.
4. We know questions will arise concerning insurance and/or financial matters with our staff. We hope you get some assistance from your insurance company, but remember your insurance contract is between you and your company. It is ultimately your responsibility to follow up with your insurance and to pay the remainder that is due.

Signature: ______Date: ______

Appleton Prosthodontics

HIPAA OMNIBUS RULE

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims.

Date: ______

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.

______

Please print name of Patient Please signfor Patient / Guardian of Patient

______

Legal Representative / Guardian Relationship of Legal Representative / Guardian

Your comments regarding Acknowledgements or Consents: ______

______

HOW DO YOU WANT TO BE ADDRESSED WHEN SUMMONED FROM THE RECEPTION AREA:

 First Name Only  Proper Sir Name  Other ______

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

(This includes step parents, grandparents and any care takers who can have access to this patient’s records):

Name: ______Relationship: ______

Name: ______Relationship: ______

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I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA:

 Cell Phone Confirmation

 Home Phone Confirmation

 Work Phone Confirmation

 Any of the Above

I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA:

 Cell Phone Confirmation

 Home Phone Confirmation

 Work Phone Confirmation

 Any of the Above

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

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Office Use Only

As Privacy Officer, I attempted to obtain the patient’s (or representatives) signature on this Acknowledgement but did not because:

It was emergency treatment _____

I could not communicate with the patient_____

The patient refused to sign_____

The patient was unable to sign because_____

Other (please describe)______

Signature of Privacy Officer