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MEDICAL HISTORY FORM

DATE: ________

Patient Information: Patient’s Name: Last First Social Security #: Sex: M / F Date of Birth: If patient is a Minor , Parent’s or Guardian’s Name: Patient’s Address: City: State: Home Phone: Work Phone: Employer: Occupation: Name/Address/Phone No. of nearest relative not living with you:

How did you hear about us? Please check below:  Yellow Pages  Friend/Relative  Mail Coupon  Health Fair/Event

Middle Initial Age: Apt #: Zip Code: Other: No. of Years Employed:

 News Paper. Which paper?_____________________  Other ______________________________________

Reason for today’s dental visit: Date of last dental visit:

Reason:  Yes  Yes  Yes  Yes  Yes  Yes

Are you apprehensive about dental treatment? Are your teeth sensitive to hot, cold, sweets or pressure? Do your gums bleed, feel tender or irritated? Do you have discolored teeth that bother you? Are you unhappy with the appearance of your teeth? Are you now seeing a physician? If so, what’s the condition being treated? Name & Address of physician: What medication(s) are you taking now? Are you pregnant?  Yes  No

     

No No No No No No

How long?

Mark any of the following which you have had or have at present:        

Heart Disease Heart Murmur Emphysema Scarlet Fever Rheumatism Venereal Disease Hepatitis Bruise Easily

       

Heart Pacemaker Diabetes Blood Disease Tuberculosis Pain in Jaw Kidney Trouble Hemophilia Sickle Cell Disease

       

Ulcers  Thyroid Disease Anemia  High Blood Pressure HIV+  Cancer/Leukemia Arthritis  Rheumatic Fever Glaucoma  Cortisone Medicine Hay Fever  Nervousness Asthma  Epilepsy/Seizures OTHER ________________________________

Mark any of the following Medications you are allergic to:  Local Anesthetics  Sulfa Drugs  Iodine

 Penicillin or other antibiotics  Codeine or other narcotics  Aspirin  Barbiturates, sedatives or sleeping pills  Other _________________________________________________________

To the best of my knowledge, all of the preceding answers are true and correct. If any change occurs in my health or medicines I take, I will inform my Dentist. Signature of Patient/Parent/Guardian


Consent of Disclosure (FOR THE USAGE AND/OR DISCLOSURE OF PROTECTED HEALTH INFORMATION)

I HEREBY GIVE CONSENT TO TOOTH TIME FAMILY DENTISTRY AND HEALTHCARE PROVIDERS FURNISHING CARE WITHIN TOOTHTIME FACILITIES TO USE AND DISCLOSE MY PROTECTED HEALTH INFORMATION FOR THE PURPOSES OF TREATMENT, PAYMENT AND HEALTHCARE OPERATIONS. YOU HAVE THE RIGHT TO REQUEST RESTRICTION ON THE USAGE AND DISCLOSURE OF YOUR PROTECTED HEALTH CARE OPERATIONS. WE ARE NOT REQUIRED TO GRANT YOUR REQUEST. HOWEVER, IF WE DO, THE RESTRICTION WILL BE OBLIGATORY TO US. Our posted Privacy Policy provides more detailed information about the usage and disclosure of your protected health information. You have the right to review our posted Privacy Policy before you sign this consent. We reserve the right to amend the terms of our posted Privacy Policy. You may obtain a copy of the current Policy by asking our office manager. You may cancel this consent at any time. Your cancellation must be in writing, signed by you or on your behalf, and delivered to the address at the bottom of this form. This may be delivered by person or by mail. But it will only be effective from the moment we actually receive it. Your cancellation will not be effective to the extent that we or others have acted in reliance upon this consent. PRINT NAME OF PATIENT: SIGN:

DATE: (Patient or Legal Guardian)

PRINT YOUR NAME:

RELATIONSHIP:

Toothtime Family Dentistry – New Braunfels, PLLC 206 Stone Gate Dr. New Braunfels, TX 78130


Notice of Privacy Practices THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. Our commitment here at Tooth Time Family Dentistry is to serve our patients with professionalism and care, making sure at all times to protect the privacy and security of all protected health information. During the course of serving your interests, it may be necessary to share information with other healthcare providers or business associates. The following are examples of instances where information may be shared:  During treatment, it may be necessary to acquire a laboratory analysis.  For payment purposes, we may use the services of a billing company.  During health care operations, we may require a second opinion. We, here at Tooth Time are committed to obeying all Federal, State and Local laws and regulations regarding privacy practices. If any uses or disclosures, other than the ones listed above are needed, information will only be released with written authorization, which may be revoked at any time by the individual as provided for by law. If you have any questions or comments regarding your protected health information, please feel free to contact our Compliance Officer: Jeniece L. Carter (830) 625-6410 I have read and understand the above Notice of Privacy Practices. SIGN:

DATE: (Patient or Legal Guardian)

Toothtime Family Dentistry – New Braunfels, PLLC 206 Stone Gate Dr. New Braunfels, TX 78130

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