Root canal referral patients questionnaire

Name:

DOB:

Medical History

Name of Physician:

Date of last physical:

Are you currently in good health?:

Yes

Have you ever been told you need to take antibiotics before a dental appointment?:

Yes

Are you presently under the care of your physician?:

Yes

If yes, why?:

Are you presently taking any pills, drugs or medications?:

Yes

If yes, which ones and for how long?:

Are you presently taking, or have ever taken any Bisphosphonates? :

Yes

If yes, which one(s) and for what reason?:

Do you have any drug allergies? :

Yes

If yes, which drugs?:

Do you have any other allergies?:

Yes

If yes, which ones?:

Do you smoke?:

Yes

If yes, how many per day?:

Are you pregnant?:

Yes

If yes, how far along?:

Have you had any injury to your jaw or to your face? :

Yes

Have you been hospitalized in the past? :

Yes

If yes, for how long?:

Have you had any surgery in the past?:

Yes

If yes, what type of surgery?:

Personal Information

ALL INFORMATION IS STRICTLY CONFIDENTIAL

Address:

Street or Box #

City/Province/Postal Code:

Date of Birth:

Home Phone No.:

Work Phone No.:

Cell Phone No.:

Email Address:

Please mark as you read each paragraph

APPOINTMENTS:

I am aware that appointment times are reserved for me. If I am unable to keep an appointment I will allow 2 business days notice to avoid a late cancellation or missed appointment fee($100/hr).

PERMISSION TO TREAT:

This is to certify that I (the undersigned or guardian of a minor), consent to the performing of the dental and oral procedures to be necessary or advisable, including the use of local anaesthesia. I authorize the release of any records that are relevant to the processing and payment held by Dr. Nasralla Inc, to any appropriate health professional, licensing or regularity body for the purpose of administrative audit.

ESTIMATES:

I am aware that any estimates given could change due to unforeseen circumstances and that I am responsible for any balance on my account.

Dental Insurance

You may not know this; dental insurance is an individual commodity. There are thousands of insurance companies and each company has thousands of individual group plans, each group plan is different from the next. There is no possible way a dental office would be able to know precise information about your dental plan. Dental offices are not directly connected to insurance companies, and now due to the privacy act (January 2004) most dental plans will not release information to the dental office. We must rely solely on our clients to give us the plan information. Some insurance companies will go so far as to only send the policy holder the information required by the dental office to submit your claims or for sending preauthorizations on your behalf.

Please check:

I understand what I have read in regards to dental insurance, and realize that in the end I am responsible for my account balance with or without help from my dental plan

Our office will deal with your dental insurance one of two ways. :

Option 1 “Non-Assignment” You (the patient) will pay the full amount of your dental appointment for each visit and we (the dental office) will do all the paper work and have your dental plan reimburse you directly.(On average dental insurance will reimburse you within 1-2 weeks)

Option 2 “Authorized Assignment” You (the patient) will pay in full any patient share owing for each appointment and we (the dental office) will submit all the paper work and wait for payment from your dental plan. In addition you will consent to authorize us to debit your credit card (which will be kept on file) for any balance owing that your dental plan declines to pay either in part or in whole.

(Please be aware that there are some dental plans that we will only deal with “Non-Assignment” and some plans that are set up by your employer to be “Non-Assignment”) *OPTION 2 ONLY AVAILABLE IF YOU ARE ABLE TO SUPPLY ALL NECESSARY INSURANCE AND CREDIT CARD INFORMATION!

Suckerfish