Patient Form - Dana Point Dental - Dentist Dana Point CA

Patient Information

Patient Name *

MI

Last *

DOB *//

Address *

Address Line 1

Address Line 2

City

State

Zip Code

Home Phone *

Cell Phone *

May we leave a detailed message? *

Email *

Are you a Veteran

In case of emergency, contact (Please specify someone not living in your household)

Name *

Relationship to Patient *

Home Phone

Cell Phone

What is your current Occupation?

Who is your current Employer Name?

Referral information

Please let us know how you heard about us. *

Smile Assessment

If you could wave a wand and change anything about your smile, what would you change? *

How would a healthy, confident smile improve your life? *

Do you feel embarrassed with your current smile? What about your smile makes you feel this way? *

Is the brightness of your smile important to you? *

If there were a way to whiten your teeth at a very reasonable investment would you be interested? *

How can we help you feel more confident with your smile?

Which of the following changes would help get you get the smile you’ve always wanted: Check All that Apply *

Dental History

On a Scale of 1 to 10, with 10 being the highest rating

What is the reason for your visit today? *

Are you in pain now? *

Do you feel nervous about dental treatment? *

Have you ever had an upsetting dental experience? *

Date of your last dental visit? *//

Previous Dentist’s name: *

Why did you leave your previous dentist? *

What did you like about your previous dental office? *

What did you dislike about your previous dental office? *

How often do you brush your teeth? *

How often do you floss? *

What other dental aids (waterpik, Electric toothbrush) do you use ? *

Are you noticing any :

Sensitivity to Cold or Hot?

Sensitivity to Sweets?

Sensitivity to Biting/Chewing

Bad tastes or odors

Cold sores, blisters, canker sores?

Gums or Bone concerns?:

Do your gums bleed or hurt?

Have you noticed any loose teeth or changes to your bite?

Does food tend to get caught in between your teeth?

Have you ever had Periodontal treatment?

Are you aware if you:

Clench or grind your teeth while you are awake or asleep?

Bite your lips or cheeks regularly

Hold objects with our teeth (Pencils, pens, fingernails)

Have tired jaws, especially in the morning?

Mouth breathe while awake or asleep?

Snore, or have difficulty sleeping?

Have you ever experienced:

Clicking or popping of the jaw?

Pain in the joint, ear or side of face?

Difficulty opening or closing your mouth?

Head, Neck, or shoulder pain?

Muscle pain or soreness in the head, neck or shoulders?

A serious injury to the mouth or head?

In the past 5 years, have your teeth changed (become shorter, thinner, or worn) or has your bite changed?

Do you have problems with your jaw joint? ( pain, sounds, limited opening, locking, popping).

Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together?

Do you have difficulty chewing gum, carrots, nuts, bagels, or hard foods?

Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together?

Have you ever had:

Orthodontic treatment?

Oral Surgery?

Your bite adjusted?

A bite plate or mouthguard?

CPAP machine?

Any other information about your dental treatment that you would like us to know?

Medical History List of Conditions

Please indicate which of the following you have had, or have at present:

COVID-19 *

AIDS/HIV

Kidney Disease

Alcohol Addiction

Liver Disease

Arthritis, Rheumatism

Low Blood Pressure

Anemia

Mitral Valve Prolapse

Artificial Heart Valves

Nervous Problems

Artificial Joints

Neurological Disorders

Asthma

Pacemaker

Back Problems

Psychiatric Care

Bleeding Abnormally with Extractions or Surgery

Radiation Treatment

Blood Disease

Recreational Drugs

Breast Augmentation

Respiratory Disease

Cancer

Smoke Cigarettes

Chemotherapy

Rheumatic Fever

Chemical Dependency

Scarlet Fever

Circulatory Problems

Shortness of Breath

Congenital Heart Lesions

Sinus Trouble

Cortisone Treatments

Skin Rash

Cough, persistent or bloody

Special Diet

Stroke

Diabetes

Emphysema

Swollen Feet or Ankles

Epilepsy

Swollen Neck Glands

Fainting/Dizziness

Smokeless Tobacco

Headaches

Tonsillitis

Heart Murmur

Tuberculosis

Heart (surgery, disease, attack)

Tumor/Growth on Neck

Hemophilia

Thyroid Problems

Hepatitis

Weight Loss Unexplained

Herpes/Cold Sores

Do you wear contact lenses?

High Blood Pressure

Do you take aspirin daily?

Jaundice

Blood Thinners

Do you currently have or have you had any disease, conditions, or problems not listed?

Physician’s Name *

Phone Number *

How would you assess your current health?

Are you currently under the care of a physician?

Have you been in the hospital in the last 5 years?

What was the date of your last physical?//

Have you ever taken any bisphosphonates for osteoporosis such as Fosomax, Actonel, Boniva, Prolia, or others?

Do you use more than 2 pillows to sleep?

Do you smoke Cigarettes, Cigars, marijuana, E-cigarettes, Vape or use smokeless tobacco?

Have you ever needed to premedicate prior to a dental procedure?

Are you taking any Medicines? *

Preferred Pharmacy Name

City (Pharmacy)

Phone (Pharmacy)

Any other information you feel the doctors should know in order to best care for you?

Are you pregnant?

Could you be pregnant?

Are you nursing?

Are you taking Birth Control Pills?

What are some of your hobbies/interests?

Do you have any important upcoming events in your life?

Who is your favorite sports team?

Insurance information

Do you have Dental Insurance ?

DOB//

Patient-Dentist Arbitration Agreement

Article I.

It is understood that any dispute as to dental malpractice, this, as to whether any dental services rendered under this contract were unnecessary or unauthorized or were improperly, negligently or incompetently rendered, would be de-termined by submission to arbitration as provided by California Law, and not by a lawsuit, or resort to court process, except as California law provides for judicial review or arbitration proceedings. Both parties of this contract by entering into it, have given up their constitutional right to have any such dispute decided in a court of law before a jury, and in-stead are accepting the use of arbitration.

Treatment in this office is contingent upon both parties consenting to this Arbitration Agreement.

Article I.

A. Parties to the Agreement:
The term “patient” as used in this agreement includes the undersigned individual, his or her spouse, children (whether born or unborn), and heirs, assigns or personal representatives. The individual signing this Agreement signs it on behalf of the foregoing persons, and intends to bind each of them to arbitration to the full extent permitted by law. The term “doctor” as used in this agreement includes the undersigned doctor and his or her professional corporation or partnership, and any employees, agents, successors in interest, heirs and assigns of the foregoing individuals or enti-ties and independent contractors. The doctor signing this agreement signs it on behalf of all the foregoing individual and entities, and intends to bind each of them to arbitration to full extent permitted by law.
B. Treatment Covered:
Patient understands and agrees that any dispute of the sort descried in Article I between doctor and patient will be subject to compulsory, binding arbitration.
C. Coverage of Pre-Natal Claims (If Applicable):
Patient understands and agrees that, if doctor treats her during pregnancy, any dispute or sort descried in Article I as to dental treatment rendered to or affecting the unborn child will be subject to compulsory, binding arbitration.

Article III.

A. Informal Resolution of Disputes:
In the event patient feels that a problem has arisen in connection with the dental care rendered by doctor to patient, patient will promptly notify doctor so that doctor may have the opportunity to resolve the matter. Notice may be given orally or in writing, and shall stop the running or statute of limitations forninety (90) days.
B. Method of Initiating Arbitration:
If the dispute is not resolved by mutual Agreement within ninety (90) days, patient may initiate arbitration by notifying doctor to that affect. The arbitrator shall be selected by the chief administrator of JAMS ENDISPUTE. The arbitrator must be selected within twenty-one (21) days of the signature on the receipt for a letter sent certified mail return re-ceipt request demanding that a dispute submitted to arbitration. Following the selection of the arbitrator, arbitration must be held within thirty (30) days.
C. Applicable Law:
The arbitration shall be conducted pursuant the California Arbitration Act (C.C.P. 1280-1296). The Arbitrator shall, in addition, have authority to order such other discovery as he/she deemed appropriate for a full and fair hearing of the case. A determination on the merits shall be rendered in accordance with the law of the State of California, including the provisions of the Medical Injury Compensation Reform Act 1975 which shall apply to the same extent as if to dis-pute or pending before a Superior Court of the State of California.
The arbitrator shall not have the power to commit errors of law or legal reasoning, and the arbitrator’s decision may be vacated or corrected pursuant the California Code of Civil Procedure Sections 12806.2 or 12086.6 for any such error. The prevailing party shall be entitled to attorney fees.

Article IV.

A. Revocation:
If you are signing this agreement and then change your mind, the law permits you to revoke the Agreement providing you give your doctor written notice within thirty (30) days of signing that you want to withdraw from the Agreement. However, doctor and patient agree that any claim arising for dental services rendered prior to revocation shall be sub-jected to arbitration. Furthermore, doctor is not obligated to continue the doctor/patient relationship should you de-cide to withdraw from the agreement.

NOTICE: BY SIGNING THIS CONTRACT, YOU ARE AGREEING TO HAVE ANY ISSUE OF DENTAL MALPRACTICE DECIDED BY MUTUAL ARBITRATION AND YOU ARE GIVING UP RIGHT TO JURY OR COURT TRIAL, SEE ARTICLE I OF THIS CON-TRACT.

Signature *

Date *//

Hippa Agreement

Protecting Your Confidential Health Information is Important to Us

Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully.

Our Promise!

Dear Patient:
This is not a meant to alarm you! Quite the opposite! It is our desire to communicate to you that we are taking the new Federal (HIPAA-Health Insurance Portability and Accountability Act) laws written to protect the confidentiality of your health information seriously. We do not ever want you to delay treatment because you are afraid your personal health history might be unnecessarily made available to others outside of our office.

So what has changed? Why a privacy policy now? Very good questions!

The most significant variable that has motivated the Federal government to legally inforce the importance of the privacy of health information is the rapid evolution of computer technology and its use in healthcare. The government has appropriately sought to standardize and protect the privacy of the electronic exchange of your health information. This has challenged us to review not only how your health information is used within our computers but also with the internet, phone, faxes, copy, machines, and charts. We believe this has been important exercise for us because it has disciplined us to put in writing the policies and procedures we use to ensure the protection of your health information everywhere it is used.

We want you to know about these policies and procedures which we developed to make sure your health information will not be shared with anyone who does not require it. Our office is subject to State and Federal law regarding the confidentiality of our health information and in keeping with these laws, we want you to understand our procedures and your rights as our valuable patient.

We will use and communicate your HEALTH INFORMATION only for the purposes of providing your treatment, obtaining payment and conducing health care options. Your health information will not be used for other purposes unless we have asked for and been voluntarily given your written permission.

How your HEALTH INFORMATION may be used:

To Provide Treatment

We will use your HEALTH INFORMATION within our office to provide you with the best dental care possible. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between hygienist, dental assistant, dentist, and business staff. In addition, we may share your health information with physicians, referring dentist, clinical and dental laboratories, pharmacies or other health care personnel providing you treatment.

To Obtain Payment

We may include your health information with an invoice use to collect payment for treatment you received in our office. We may do this with insurance forms filed for you in the mail or sent electronically. We will be sure to only work with companies with similar commitment to the security of your health information.

To Conduct Health Care Operations

Your health information may be used during performance evaluation of our staff. Some of our best teaching opportunities use clinical situations experienced by patients receiving care at our office. As a result, health information may be included in training programs for students, interns, associates, and business and clinical employees. It is also possible that health information will be disclosed during audits by insurance companies or government appointed agencies as part of their quality assurance and compliance reviews. Your health information may be reviewed during the routine processes of certification, licensing or credentialing activities.

In Patient Reminders

Because we believe regular care is very important to your oral and general health, we will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may be of interest to you or your family. These communications are an important part of our philosophy of partnering with our patients to be sure they receive the best preventive and restorative care modern dentistry can provide. They may include postcards, letters, telephone reminders, or electronic reminders such as email (unless you tell us that you do not want the receive these reminders.

Abuse or Neglect

We will notify government authorities if we believe a patient is the victim of abuse, neglect, or domestic violence. We will make this disclose only when we are compelled by our ethical judgment, when we believe we are specifically required or authorized by law or with the patient’s agreement.

Public Health and National Security

We may be required to disclose to Federal officials or military authorities health information necessary to complete an investi-gation related to public health or national security. Health infor-mation could be important when the government believes that the public safety could benefit when the information could lead to the control or prevention of an epidemic or the understanding of new side effects of a drug treatment or medical device.

For Law Enforcement

As permitted or required by State of Federal law, we may dis-close your health information to a law enforcement official for certain law enforcement purposes, including, under certain lim-ited circumstances, if you are a victim of a crime or in order to report crime.

Family, Friends and Caregivers

We may share your health information with those you tell us will be helping you with home hygiene, treatment, medications, or payment. We will be sure to ask your permission first, In the case of an emergency, where you are unable to tell us what you want we will use our very best judgement when sharing your health information only when it will be important to those participating in providing your care.

Authorization to Us or Disclose Health Information

Other than what is stated above or where Federal, State or Local law requires of us, we will not disclose your health information other than with your written authorization. You may revoke that authorization in writing at any time.

Patient Rights

This new law is careful to describe that you have the fallowing rights to your health information.

Restrictions

You have the right to request restrictions on certain uses and disclosures of your health information. Our office will make eve-ry effort to honor reasonable restriction preferences from our patients.

Confidential Communications

You have the right to request that we communicate with you in a certain way. You may request that we only communicate your health information privately with no other family members pre-sent or through mail communications that are sealed. We will make every effort to honor your reasonable requests for confi-dential communications.

Inspect and Copy Your Health Information

You have the right to read, review and copy your health information, including you complete chart, x-rays and billing records. If you would like a copy of your health information, please let us know. We may need to charge you a reasonable fee to duplicate and assemble your copy.

Amend Your Health Information

You have the right to ask us to update or modify your records if you believe your health information records are incorrect or incomplete. We will be happy to accommodate you as long as our office maintains this information. In order to standardize our process, please provide us with your request in writing and de-scribe your reason for the change.
Your request may be denied if the health information record in question was not created by our office, is not part of our records or if the records containing your health information are deter-mined to be accurate and complete.

Documentation of Health Information

You have the right to ask us for a description of how and where your health information was used by our office for any reason other than treatment, payment or health operations. Our docu-mentation procedures will enable us to provide information on health information usage form April 14, 2003 and forward. Please let us know in writing the time period for which you are interested. Thank you for limiting your request to no more than six years at a time. We may need to charge you a reasonable fee for your request.

Request a Paper Copy of this Notice

You have the right to obtain a copy of this Notice of Privacy Prac-tice directly from our office at any time. Stop by or give us a call and we will mail or email a copy to you.

We are required by law to maintain the privacy of your health information and to provide to you and your representative this Notice of our Privacy Practices. We are required to practice the policies and procedures described in this notice but we do re-serve the right to change terms of our Notice. If we change our privacy practices we will be sure all our patients receive a copy of the revised Notice.
You have the right to express complaints to us or to the Secre-tary of Health and Human Services if you believed your privacy rights have been compromised. We encourage you to express any concerns you may have regarding the privacy of your infor-mation. Please let us know of your concerns or complaints in writing.

Patient Acknowledgment

Patient Name(s) *

Thank you very much for taking the time to review how we are carefully using your health information. If you have any ques-tions we want to hear from you. If not, we would appreciate very much you acknowledging your receipt of our policy by signing and returning this paper. We look forward to seeing you again soon!

Signature *

Date *//