HOW WERE YOU REFERRED TO OUR OFFICE?
HOW WERE YOU REFERRED TO OUR OFFICE? Name ___________________________ SELECT UP TO 3 CHOICES AND PLACE THEM IN ORDER OF 1,2, AND/OR 3 ON HOW YOU MADE THE DECISION TO COME TO OUR OFFICE. Cedar Rd Medical Assoc Children's Dentistry Offices DentalPlans.com Dinner & A Movie Voucher Dr.Pearl’s Postcard/Newspaper Announc Elementary Schools CH Elementary Schools VB Employers Facebook Family Member Fitness Centers Friends Health Fair Events Insurance Companies Internet Search: Konikoff Dentistry Website____ Other Website(Please List)_________ Klar and Voorhees Konikoff Periodontics Miranda, Josue D MD Nimmo Pediatrics Office Location/Signage Other Orthodontic Office Other Physician's Office Postcards Roy Orthodontics Television Commercial Tricare Twitter Urgent Care Facilities Walk In Yellow Pages Patient Information (CONFIDENTIAL) Konikoff Dental Associates, Inc. Date ___________________ Circle:Male/Female Check Appropriate Box: Patient's Social Security # ______________________ Child Single Married Age: __________ Divorced Widowed Separated Birthdate: __________________ Name____________________________________________________________ Home Phone ___________________ Home Address____________________________________________City____________________State________Zip_________ Email Address____________________________________________ Cell Phone _____________________________ Patient’s Employer___________________________________________ How Long? ___________ Work Phone____________ Patient's Employer Address______________________________________ Position___________________________________ City _____________________________________ State _____ Zip_________ If Student, Name of School/College _______________________City ___________State_____ Part Time Full Time Has anyone in your family been seen at any of our office locations? If yes, who______________________________ Person to Contact in Case of Emergency________________________________ Phone______________________ Family Information Spouse / Parent or Guardian Name ________________________________S.S.#__________________ Birthdate_______ Address ____________________________________City ____________________________ State __________ Zip ________ Spouse or Parent's Employer __________________________ Spouse or Parent's Work Phone ________________________ Additional Parent or Guardian Name ______________________________S.S.#___________________ Birthdate________ Address ____________________________________City ____________________________ State __________ Zip ________ Spouse or Parent's Employer __________________________ Spouse or Parent's Work Phone ________________________ Dental Insurance Information Circle: Employer coverage or Individual plan Subscriber Name __________________________________________________ Birthdate __________________ Relationship to patient___________________ Social Security # _______________________________ Date employed ___________ Name of Employer ______________________________________ Union or Local # ______ Work Phone ________________ Address of Employer _____________________________________ City ____________________ State _______ Zip________ Insurance Company Name __________________________________ Group # ______________ Policy/ID #____________ Insur. Co. Address _______________________________________ City _____________________ State _______Zip________ Insur. Co. Telephone Number: ______________________ Do you have any additional Dental Insurance ? Yes No If yes, complete the following: Subscriber Name __________________________________________________ Birthdate __________________ Relationship to patient_________________________ Social Security # _______________________________ Date employed ___________ Name of Employer ______________________________________ Union or Local # ______ Work Phone ________________ Address of Employer _____________________________________ City _____________________State _______Zip________ Insurance Company Name __________________________________ Group # ______________ Policy/ID #_____________ Insur. Co. Address _______________________________________ City _____________________State _______Zip________ I ALLOW THE FOLLOWING INDIVIDUALS TO DISCUSS MY FINANCIAL, MEDICAL AND/OR DENTAL INFORMATION WITH EMPLOYEES OF KONIKOFF DENTAL ASSOCIATES. PLEASE PRINT FULL NAMES: _____________________________,______________________________ Page 1 of 3 Dental Information Reason for today's visit: Exam Emergency Consultation Are you in pain? No Yes How Long? _______ Is there anything about your dental needs we should focus on: _________________________________________________ Previous Dentist: ___________________________________________ (_______) _________________________ name phone Last Dental exam: ________________________________ Last Dental X-rays: _________________________ How would you rate your smile? 1 2 3 4 5 6 7 8 9 10 Medical Information Physician__________________________________ Office Phone __________________ Date of Last Exam ___________ 1. Are you under medical treatment now? Yes or No If yes, please explain_________________________________ ________________________________________________________________________________________________ 2. Are you taking any medication(s) including non-prescription medicine? Yes or No. If yes, please list _______________________________________________________________________________ 3. Are you currently taking or have you ever taken any of the following medication either orally or through IV? Fosamax Didrone Boniva Aredia Actonel Skelid Zometa 4. Have you had any surgeries? Yes or No If yes, please list: _______________________________________ 5. Do you have ANY DRUG, LATEX or FOOD ALLERGIES? Yes or No If yes, please list:______________ _________________________________________________________________________________________________ 6. Do you use tobacco? Yes or No How used? ________________ How much?______ How long?_______ 7. Have you ever used or are currently using recreational drugs? Yes or No 8. FOR WOMEN ONLY: Are you taking Birth Control pills? Yes or No Are you Pregnant? Yes No Approx. Delivery Date ________ Are you nursing? Yes No 9. CIRCLE BELOW If you have or have had any of the following diseases or medical conditions: Alcohol/Drug Abuse Diabetes/Hypoglycemia Hepatitis Psychiatric Problems Aggressive Steroid Therapy Difficulty Breathing Rheumatic Fever High Blood Pressure HIV+/AIDS/ARC Anemia Emphysema Rheumatoid Arthritis Artificial Bones/Joints Scarlet Fever Epilepsy Jaw Problems TMJ Artificial Valves Joint Replacement Fainting/Seizures Sinus Problems Kidney Problems Stents/shunts Asthma Frequent Headaches Bleeding Problems Frequent Neck Pain Leukemia Stomach Ulcers Cancer Stroke Glaucoma Liver Problems Chemotherapy Heart Attack Lupus Tuberculosis TB Heart Disease Mitral Valve Prolapse Chest Pains Venereal Disease Congenital Heart Defect Heart Murmur Osteoporosis High Cholesterol Heart Surgery Defibrilator Pacemaker Other: ____________ Please notify our office immediately if you have/have had any of the conditions, marked with a . We may need written authorization from your physician to treat you. X-RAYS - We pride ourselves in delivering the highest standard of care; therefore complete diagnostic x-rays are necessary. We require complete series of x-rays on our new patients. If you have had this series in the past three years we ask that you bring them with you on your initial visit. Notice to test blood. A law was enacted in Virginia in 1989 which authorized health care providers to test their patients for HIV antibodies when the health care provider is ACCIDENTALLY EXPOSED to blood or body fluids in a manner which may transmit the human immunodeficiency virus (HIV). However, you would be informed before any of your blood would be tested for HIV antibodies. The testing would be explained and you would be given the opportunity to ask any questions you might have. In addition, in the event that one of our health care providers is exposed to potentially infectious body fluids, permission is hereby granted to test my blood for infectious Hepatitis B. Page 2 of 3 FINANCIALINFORMATION–PLEASEREADCAREFULLY. Itisthegoalofourpracticetoprovidenotonlythefinestcareavailable,butalsotoprovidefinancial servicesthatdonotcauseunduehardships.Patientswillbescheduledfortreatmentafterfinancial arrangementsaremadewithourFinancialAssociatesregardingalltreatment.OURFINANCIAL ASSOCIATESAREAVAILABLETOANSWERANYQUESTIONSYOUHAVE. Ourofficerequiresa24hournoticeifyouarenotabletomakeyourappointment.Ifwedonotreceive thisnotice,afeewillbechargedtoyouraccount. X‐rayRequirements‐‐Weprideourselvesindeliveringthehigheststandardofcare;therefore, completediagnosticx‐raysarenecessary.Werequireacompleteseriesofx‐raysonnewpatientsand patientswhohavenotbeentoseeusonaregularbasis.Ifyouhavehadthisseriesdonewithanotherdentist inthepastthreeyears,weaskthatyoubringthemwithyouonyourinitialvisit. IF YOU DO NOT HAVE THEM OR ARE NOT ABLE TO RETRIEVE THEM FROM YOUR PRIOR DENTIST BEFORE YOUR APPOINTMENT WITH US, WE WILL NEED TO TAKE X-RAYS AND BILL YOU. InsurancePolicy—Thepatientisalwaysexpectedtopayhis/herportionatthetimeofservice, includingco‐payanddeductibles.Asacourtesytoallofourpatientswithinsurance,wewillfiledental serviceswithyourprimaryinsurancecompany,andifapplicableyoursecondaryinsurance.Thenormal timeallowedforinsuranceresponseis30days.Anychargesremainingonyouraccountafteryour insurancepaysareultimatelyyourresponsibility. PaymentPolicy‐Ourofficerequirespaymentinfullforallservicesrenderedatthetimeofvisit, unlessotherarrangementshavebeenmadewiththefinancialdepartment.Ifotherarrangementsaremade withourfinancedepartment,thepatientauthorizesKonikoffDentalAssociates,Inc.tomakesuchinquiries withanycreditbureauregardingfinancialresponsibilitiesthataredeemednecessary. CollectionPolicy‐Ifyouraccountbecomesdelinquentandnofinancialarrangementshavebeen made,youwillberesponsibleforlegalfees,interestcharges,331/3%attorneyfees,andanyotherexpenses incurredincollectingyouraccountbalance.Allworkmustbepaidinfullatthetimeofserviceonceyour accounthasbeensatisfiedwiththeattorney. AUTHORIZATIONSFROMPATIENT IauthorizeKonikoffDentalAssociates,Inc.toperformanynecessaryservicesneededduringdiagnosisand treatment.Ialsoauthorizethereleaseofanyrequiredinformationtooutsidehealthpractitionersandforthepurpose ofprocessinginsuranceclaims. Iunderstandthatmyinsurancepolicyisacontractbetweenmeandmyinsurancecompany ies andthatIam responsibletoKonikoffDentalAssociates,Inc.forallfees. Iauthorizeandrequestmyinsurancecompany ifapplicable topaydirectlytothedentistordentalgroup insurancebenefitsotherwisepayabletome.Iunderstandthatmydentalinsurancecarriermaypaylessthanthe actualbilledservicesandthatIamresponsiblefortheremainingbalance. Iunderstandtheaboveinformationandguaranteethisformwascompletedcorrectlytothebestofmy knowledgeandunderstanditismyresponsibilitytoinformthisofficeofanychangestotheinformationIhave provided. Signature_______________________________________________Date_____________ ______AdultPatient______ParentorGuardian______Spouse’sSignature PowerofAttorneyRequired Page 3 of 3
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