Heartland Periodontics Patient Packet Form

Dr. Michael G. Kirsch, DDS, MS

WELCOME TO OUR OFFICE

Thank you for choosing our office. In order to provide you with the highest quality and most complete health care, we ask that you please complete the following information. In order to assure you of the confidentiality of your health information, please see our Notice of Privacy Policy.

* denotes REQUIRED field.

Please Select

Dr.

Mr.

Mrs.

Ms.

Miss

Last Name *

First Name *

Address *

City/ State/ Zip *

Birth Date *

Social Security #

Home Phone

Cell Phone

Employer

Work Phone

Address

City/ State/ Zip

Email Address

Please select Email type

Work

Personal

Name of Referring Dentist

Phone

In Case of Emergency

Phone

PERSON RESPONSIBLE FOR ACCOUNT

Name

Daytime Phone

Address

City/ State

DENTAL INSURANCE INFORMATION

Insurance Company

Insured's Employer

Company Address

City / State / Zip

Group #

ID #

Insured's Name

Relation:

Insured's Birth Date

Insured's Social Security #

I acknowledge that I have received a copy of this office's NOTICE OF PRIVACY POLICY

Initials:

Payment is due in full at time of treatment unless prior arrangements have been approved. If this office agrees to accept my insurance, I understand that I am responsible for payment of services rendered and also responsible for paying any co-payment and deductible that my insurance does not cover.

Signature *

Date

MEDICAL HISTORY

Patient Name *

Birth Date *

Please select YES or NO to the following medical questions below

Do you require antibiotics before dental treatment?

PRE-MED DOSAGE

NAME *

BP:

Pulse:

Date:

Initials:

Continued Medical History

Your current physical health is:

Excellent

Good

Fair

Poor

Are you currently under the care of a physician?

Please explain

Please list all physicians and their specialty:

Family Physician:

Phone:

Address:

Physician:

Specialty:

Phone:

Address:

Physician:

Specialty:

Phone:

Address:

Physician:

Specialty:

Phone:

Address:

Preferred Pharmacy:

Phone:

List ALL medications you are taking and reason. Include prescription, supplements, and over the counter. (Include any blood thinning herbal medications or supplements such as: Vitamin E, garlic, fish oil, any oils, bilberry, bromelain, cat’s claw, devil’s claw, dong quai, evening primrose, feverfew, ginger (at high doses), ginkgo biloba, grape seed, ginseng, green tea, horse chestnut, and turmeric.)

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

Name of Medication

Dosage

Reason

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.

Signature *

Date

Name *

Date *

Dental History

Special Considerations

Office Use Only

Consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations

I, * , understand that as part of my health care, Heartland Periodontics, PA originates and maintains paper and/or electronic records describing my health and dental history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand that this information serves as:

A basis for planning my care and treatment and a means of communicating among the many health professionals who contribute to my care.
A source of information for applying my diagnosis and surgical information to my bill.
A means by which a third-party payer can verify that services billed were actually provided, and
A tool for routine healthcare operations such as assessing quality and review the competence of healthcare professionals.

I understand and have been provided with a notice of privacy practices that provide a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

The right to review the notice prior to signing this consent
The right to request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.528

I understand that Heartland Periodontics, PA is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that Heartland Periodontics, PA reserves the right to change their notice and practices at any time provided such changes are applicable by law and make the new Notice available upon request.

I wish to have the following restrictions to the use or disclosure of my health information:

I wish to allow the following persons access to my health information:

I understand that as part of Heartland Periodontics, PA’s treatment, payment or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosure via fax. I fully understand and accept the terms of this consent.

Patient's Signature *

Parent / Guardian

Date

Office Use (received by /date)

Patient Name Validation