Patient Form - Streitz Dental Arts

PATIENT INFO
Last Name
First Name
M.I.
Prefers to be Called By
Address
City
State
Zip
Home Phone
Cell
Work
Gender
- Male
- Female
Birthdate
MM slash DD slash YYYY
SSN
Employer
Email
Status
- Minor
- Single
- Married
- Divorced
Drivers License or State ID
Whom may we thank for referring you?
IF PATIENT IS UNDER 18, PLEASE COMPLETE THE FOLLOWING INFORMATION
- Father's Name
- Address
- City, State, Zip
- Home Phone
- Cell Phone
- Employer/Phone
- Mother's Name
- Address
- City, State, Zip
- Home Phone
- Cell Phone
- Employer/Phone
- EMERGENCY CONTACT
- Name
- Relationship
- Home Phone
- Cell Phone
- Closest relative not living with you
- Name
- Relationship
- Home Phone
- Cell Phone
PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT
Name
- Self
- Name
Name
Relationship to Patient
Address
City
State
Zip Home
Phone
Cell Phone
- PRIMARY DENTAL INSURANCE
- Policy Holder
- DOB
  MM slash DD slash YYYY
- SSN
- Employer
- Relationship to Patient
- Insurance Company
- ID
- Grp
- Ins. Co. Phone
- SECONDARY DENTAL INSURANCE
- Policy Holder
- DOB
  MM slash DD slash YYYY
- SSN
- Employer
- Relationship to Patient
- Insurance Company
- ID
- Grp
- Ins. Co. Phone
HIPPA Privacy Form Acknowledgement of Receipt Consent for Treatment and Assignment of Benefits
The doctors or staff may contact me at my place of employment:
- Yes
- No
If unable to reach me:
- you may leave a detailed message on my home or cell phone
- you may leave a detailed message on my work phone
- you may email me
Email
I authorize the release of information including the diagnosis, records, examination rendered to me and claims information. This information may be released to:
- I authorize the release of information including the diagnosis, records, examination rendered to me and claims information. This information may be released to:
Name
Relationship
Name
Relationship
Name
Relationship
No information is to be released to anyone
- No information is to be released to anyone
This Release of Information will remain in effect until terminated by me in writing.
1.I hereby authorize doctor or designated staff to take x-rays, study models photographs and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis.

2.Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

3.I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications.

4.I give consent to the doctor's or designated staffs use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available.
Print Name of Patient
Signature of Patient or Gaurdian
Date
MM slash DD slash YYYY
MEDICAL HISTORY
Patient Name
Last First MI Preferred Name
Physician's name and phone:
Are you currently under medical care?
- No
- Yes
If so, for what?
Are you on any medications?
- No
- Yes
List Here
Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva or similar drugs?
- No
- Yes
If Yes, what is the name?
If you have any artificial joints (hip, knee, shoulder) or stents please list below.
Date of Surgery Type of Surgery Surgeon
Indicate which of the following you have had, or have at present
- Allergies -Seasonal
- Anemia
- Arthritis
- Artificial Heart Valve
- Artificial Joints
- Anxious/Nervous
- Aspirin Allergy
- Asthma
- Blood Disease
- Blood Pressure- High
- Blood Pressure- Low
- Blood Thinner
- Blood Transfusion
- Cancer
- Chemotherapy
- Chest Pain
- Codeine Allergy
- Cold Sores
- Cortisone Meds
- Diabetes
- Diet
- Dizziness/Vertigo
- Drug Allergy *List Below
- Emphysema
- Epilepsy
- Excessive bleeding
- Fainting
- Glaucoma
- Hay Fever
- Head Injuries
- Heart Attack
- Heart Disease
- Heart Murmur
- Congenital Heart Disease
- Hepatitis
- HIV
- Hives
- Jaundice
- Kidney Disease
- Latex Sensitive
- Liver Disease
- Mental Disorders
- Mitral Valve Prolapse
- Neurological Disorders
- Pacemaker
- Penicillin Allergy
- PRE-MEDICATE
- Radiation Treatment
- Respiratory Problems
- Rheumatic Fever
- Rheumatism
- Sinus Problems
- Stents
- Stomach Problems
- Stroke
- Sulfa Allergy
- Thyroid Problems
- Tuberculosis
- Tumors
- Ulcers
- Venereal Disease
Do you have or have you had any disease, condition, or problem not listed?
- No
- Yes
Please list
Are you aware of having allergic (or adverse) reaction to any substance or medication?
- No
- Yes
If Yes
WOMEN
Are you pregnant?
- No
- Yes
Nursing?
- No
- Yes
Taking birth control pills?
- No
- Yes
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions to the best of my knowledge. Should further information be needed, you have my permission to ask the respective health care provider or agency, who may release information to you. I will notify the doctor of any change in my health or medication.
Signature
Date
MM slash DD slash YYYY
DENTAL HISTORY
Patient Name
What is the reason for your visit today?
Date of Last Dental Visit
MM slash DD slash YYYY
Last Dental Cleaning
MM slash DD slash YYYY
Last Full Mouth X-rays
MM slash DD slash YYYY
What was done at your last dental visit?
Previous Dentist's Name
Address
State
Zip
Telephone
How often do you have dental examinations?
How often do you brush your teeth?
How often do you floss?
Have you ever used or are currently using topical flouride?
- No
- Yes
What other dental aids do you use? (Interplak, toothpick, etc)
Do you have any dental problems now?
- No
- Yes
If Yes, please describe
- Are any of your teeth sensitive to
- Hot or Cold?
  - Yes
  - No
- Sweets?
  - Yes
  - No
- Biting or Chewing?
  - Yes
  - No
- Have you noticed any mouth odors or bad tastes?
  - Yes
  - No
- Do you frequently get cold sores, blisters or any other oral lesions?
  - Yes
  - No
- Do your gums bleed or hurt?
  - Yes
  - No
- Have your parents experienced gum disease or tooth loss?
  - Yes
  - No
- Have you noticed any loose teeth or change in your bite?
  - Yes
  - No
- Does food tend to become caught in between your teeth?
  - Yes
  - No
- If yes, where?
- Do you:
- Clench or grind your teeth while awake or asleep?
  - Yes
  - No
- Bite your lips or cheeks regularly?
  - Yes
  - No
- Hold foreign objects with your teeth (pencils,pens, etc)?
  - Yes
  - No
- Mouth breath while awake or asleep?
  - Yes
  - No
- Have tired jaws, especially in the morning?
  - Yes
  - No
- Snore or have other sleeping disorders?
  - Yes
  - No
- Smoke/chew tobacco or use other tobacco products?
  - Yes
  - No
- Have you ever been told to take a pre-medication prior to dental treatment?
  - Yes
  - No
- Is there anything else about having dental treatment that you would like us to know?
  - Yes
  - No
- If Yes, Please Describe
- Have you ever had:
- Orthodontic treatment?
  - Yes
  - No
- Oral Surgery?
  - Yes
  - No
- Periodontal treatment?
  - Yes
  - No
- Your teeth ground or bite adjusted?
  - Yes
  - No
- A bite plate or mouth guard?
  - Yes
  - No
- A serious injury to mouth or head?
  - Yes
  - No
- If so, please describe, including cause
- Have you experienced
- Clicking or popping of the jaw?
  - Yes
  - No
- Pain? (joint, ear, side of face)
  - Yes
  - No
- Difficulty opening/closing mouth?
  - Yes
  - No
- Difficulty chewing on either side of mouth?
  - Yes
  - No
- Headaches, neck-aches or shoulder aches?
  - Yes
  - No
- Sore muscles (neck, shoulders)?
  - Yes
  - No
- Are you satisfied with your teeth's appearance?
  - Yes
  - No
- Would you like to keep all of your teeth all of your life?
  - Yes
  - No
- Do you feel nervous about having dental treatment?
  - Yes
  - No
- If so what's your biggest concern?
- Have you ever had an upsetting dental experience?
  - Yes
  - No
- If Yes, please describe
STREITZ DENTAL ARTS, LTD

AGREEMENT

In order to avoid any misunderstanding regarding our financial policy, it is necessary for you to read and sign this document

DENTAL INSURANCE: As a courtesy we will gladly file your claims provided you agree to the following:
- You must provide us with an insurance card and all the information necessary to verify your coverage and file your claim.
- Your insurance policy is a contract between you, your employer and the insurance company. We are NOT a party to that contract.
- If we are not an "in-network" provider of your insurance you are responsible for our fees and not what your insurance company allows or considers "usual, customary and reasonable" fees. We will be happy to submit a dental claim to expedite the reimbursement.
- Although we may estimate your insurance benefit's we are not responsible for their accuracy. Receiving our services indicates your acceptance of responsibility to pay regardless of your estimate.
- All charges not paid by your insurance company are your responsibility regardless of the reason for nonpayment. If your insurance fails to pay, you will be responsible for the balance on your account.
- Not all the services we provide are covered benefits. Benefits differ by dental plan. Fees for non-covered services along with deductibles and copayments are due at the time of service.
- I understand I am financially responsible to Streitz Dental Arts, Ltd. for charges not covered by this assignment, and that credit checks and reports may be liable for any charges not paid by my insurance company that were incurred by children or dependents of mine over the age of 18 who are listed or covered under my Dental Insurance. I agree to pay any reasonable attorneys fees or court costs incurred by Streitz Dental Arts. Ltd. in the event that I fail to pay the amounts due for services rendered and this account is sent to an attorney or collection agency. I also agree to pay collection service fee.
PATIENTS WITHOUT INSURANCE COVERAGE: We provide written estimates of fees, and payment is expected at each visit for services rendered.

PAYMENT POLICY: We accept cash, personal checks and credit cards. Third party checks are not accepted.

RETURNED CHECKS: A $10.00 charge will be applied when a check is returned by the bank. Non-payment checks not reconciled will be sent to the State's Attorney's Office.

CANCELLATION/NO SHOW POLICY: A fee of $75 will be applied for a no-show appointment, or if an appointment is cancelled or broken without a 24 hour notice. We reserve the right not to make future appointments if this occurs more than twice. Streitz Dental Arts. Ltd.defines "no-show" appointments as any scheduled appointment in which the patient either:
- Does not arrive to the appointment
- Cancels with less than 24 hours' notice
I have read and understood the Streitz Dental Arts, LTD agreement as described above.
Print Name of Patient
Signature
Date
MM slash DD slash YYYY
COVID-19 Pandemic Dental Treatment Consent and Release for Streitz Dental Arts
We strive to provide a safe environment for our patients and staff, and to advance the safety of our community. However, the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms and still be highly contagious. There are numerous ways in which the COVID-19 virus can be transmitted, including from the surface contact, respiratory droplets and aerosols, or fine particles that travel with air currents. Dental procedures create aerosols, the amount of which depends on the type of procedure. While we are committed to providing the safest environment as possible for our patients, there can be no guarantee that our facility is completely free of the COVID-19 virus and that you will not be exposed to the virus while receiving treatment despite our efforts to minimize the risk of exposure.

By signing this Consent and Release in the space provided below, you hereby release, acquit, waive all claims against, and forever discharge the practice providing my treatment (the "Practice") and its owners, successors, assigns, affiliates, officers, directors, administrators, representatives, principals, agents, dentists, employees, independent contractors, insurers, and attorneys (collectively with the practice, the "Indemnified Persons"), of and from any and all claims, charges, demands, promises, acts, agreements, costs, damages, debts, obligations, actions, causes of action (including but not limited to all avoidance actions of any type), suits in equity, expenses, executions, judgements, levies, liabilities, losses, and direct or indirect, suspected or unsuspected, accrued or unaccrued, known or unknown, present or future, asserted or unasserted, based upon, arising out of, appertaining to, or in connection with your exposure to the Severe Acute Respiratory Syndrome Coronavirus 2 or contracting coronavirus disease (COVID-19) as a result of or in connection with your entry into the Practice's office, receipt of dental treatment from the Practice or coming in contact with and Indemnified Person at the Practice's office, and all related costs, expenses, illness, or death you may suffer as a result.

The releases set forth and otherwise referenced herein shall be interpreted as broadly as possible and shall be completely binding and enforceable at law. You acknowledge that the releases and waivers provided for herein include all claims and/or costs, including but not limited to those you do not know or suspect to exist, and hereby waive all rights which may exist with regard to such claims and/or costs. You expressly waive the provisions of any federal, state, and local statute or regulation limiting release of unknown claims, including any statutory language stating as following: "A GENERAL RELEASE DOES NOT EXTEND TO CLAIMS THAT THE CREDITOR OR RELEASING PARTY DOES NOT KNOW OR SUSPECT TO EXIST IN HIS OR HER FAVOR AT THE TIME OF EXECUTING THE RELEASE AND THAT, IF KNOWN BY HIM OR HER WOULD HAVE MATERIALLY AFFECTED HIS OR HER SETTLEMENT WITH THE DEBTOR OR RELEASED PARTY, AND ANY SIMILAR LAW."

You agree that you have had the opportunity to consult with an attorney prior to executing this Consent and Release, that you voluntarily have signed the same and that you have read and understand this Consent and Release. YOU FULLY UNDERSTAND THAT, BY SIGNING THIS CONSENT AND RELEASE, YOU ARE WAIVING IMPORTANT LEGAL RIGHTS.
Patient
Signature
Print Name
Date
MM slash DD slash YYYY
For Parents/Guardians: In addition to the foregoing, we/I further waive all claims against (to the same extent set forth above), and agree to hold harmless and indemnify, the Indemnified Persons and each of them, for any illness, death, costs, expenses, or other loss sustained by the Patient which results in any way from the Patient's entry into the Practice's office, receiving dental treatment, or coming in contact with any Indemnified Person at or near the Practice's office.
Parent's/Guardian's Signature (if Patient is under 18)
The undersigned is parent(s) or legal guardian(s) of the Patient and hereby consents to the foregoing Waiver of Liability and agrees (1) on behalf of the Patient for Patient to be bound by the provisions hereof, and (2) on behalf of himself or herself and each other parent of guardian of the Patient, that all of the terms hereof, including all liability waived hereby, equally apply to and they are subject to each of them.
Signature
Print Name
Date
MM slash DD slash YYYY

Date of Surgery	Type of Surgery	Surgeon

PATIENT INFO

IF PATIENT IS UNDER 18, PLEASE COMPLETE THE FOLLOWING INFORMATION

EMERGENCY CONTACT

Closest relative not living with you

PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT

PRIMARY DENTAL INSURANCE

SECONDARY DENTAL INSURANCE

HIPPA Privacy Form Acknowledgement of Receipt Consent for Treatment and Assignment of Benefits

MEDICAL HISTORY

WOMEN

DENTAL HISTORY

Are any of your teeth sensitive to

Do you:

Have you ever had:

Have you experienced

STREITZ DENTAL ARTS, LTD

AGREEMENT

COVID-19 Pandemic Dental Treatment Consent and Release for Streitz Dental Arts

Patient

Parent's/Guardian's Signature (if Patient is under 18)