Name
Contact Information:
What is the best time to reach you ?
Whom may we thank for referring you?
Other family members seen by us?
Pharmacy Information:
Medical History:
Primary Physician
Your current physical health is?
Are you required to pre-medicate with antibiotics
when seeing the dentist?
Do you have or ever had any Medical Conditions?
Do you have any known allergies?
List all of the drugs or medications you are taking now.
Dental History:
What is your main concern for coming into our office?
Who is your dentist?
Are you currently in pain?
Are you happy with your Smile?
Are your teeth Yellow
Do your gums bleed when you brush?
Do you have any problem eating certain foods?
Do you have sensitivity to hot or cold foods?
Have you ever had periodontal disease?
Do you have loose teeth?
Do you still have your wisdom teeth?
The above information is accurate:
Date:
Consent for use and disclosure of health information
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Please read the following statements carefully before signing this form
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Purpose of consent:
By signing this form, you consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.
Notice of Privacy Practices:
You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.
Right to Revoke:
You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to: Executive Administrator, Pollack Periodontal Associates, 225 East 64th St .New York, NY 10065. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this
Consent.
SIGNATURE
I, , have received and had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare
Signature:
Date:
If this Consent is signed by a personal representative on behalf of the patient, please complete the following:
Personal Representative’s Name (print):
Relationship to Patient: