Patient Registration

The following registration information will be collected prior to your first treatment visit in our office.

Patient Registration Form

Date:_______________

Name:  _______________________________________________________

Address: ______________________________________________________

City:___________________State:____________________ Zip: _________

Home Phone:   _________________________________________________

Work Phone:  __________________________________________________

Cell Phone:  ___________________________________________________

Date of Birth:____________ Gender:_________  Ht._____  Wt.  _________

Marital Status:   ________________________________________________

Dental Insurance Company:  ______________________________________

Name of Insured:   ______________________________________________

Employer (of insured):  __________________________________________

Social Security Number (of insured):  _______________________________

Referred by:   __________________________________________________

General Dentist:   _____________________________ Phone: ___________

Primary Care Physician:  _______________________ Phone: ___________

Most Recent Physical Exam:  _____________________________________

Closest Relative:  _____________________________ Phone: ___________

Emergency Contact: ___________________________ Phone: ___________

Medical History Information

(it is in your best health interest to be accurate and honest)

Physician’s name (medical doctor):  _____________________________________

Physician’s phone:  __________________________________________________

Most Recent Physical Exam Date:  ______________________________________

Have you ever had or do you presently have:

Heart attack                                                     Yes or No       

if yes, Date:_________________________________

Heart Surgery                                                  Yes or No       

if yes, Date:_________________________________

Prosthetic Heart Valve                                    Yes or No       

if yes, Date:_________________________________    

Previous Infective Endocarditis                      Yes or No       

if yes, Date:_________________________________

Congenital Heart Disease                                Yes or No       

if yes, Date:_________________________________

Heart Murmur                                                  Yes or No       

if yes, Date:_________________________________

Mital Valve Prolapse                                      Yes or No       

if yes, Date:_________________________________

Chest Pain                                                       Yes or No       

if yes, how often, and last episode:_______________

High Blood Pressure                                       Yes or No

if yes, most recent reading:_____________________

Low Blood Pressure                                       Yes or No

if yes, most recent reading:_____________________

Stroke                                                              Yes or No       

if yes, Date:_________________________________

Artificial Joints (Hip, Knee)                           Yes or No       

if yes, Type & Date:___________________________

AIDS or HIV positive                                     Yes or No

Hepatitis A (infectious)                                   Yes or No

Hepatitis B (serum)                                         Yes or No

Hepatitis C                                                      Yes or No

Yellow Jaundice                                             Yes or No

Kidney Disease                                               Yes or No

Drug Addiction                                               Yes or No     

if, yes, Type:________________________________

Blood Transfusion                                           Yes or No

if yes, Date:_________________________________

Bleeding Problems                                          Yes or No       

if yes, Type:_________________________________

Bruise Easily                                                   Yes or No

Anemia                                                            Yes or No

Tuberculosis                                                  Yes or No     

if yes, Date:_________________________________

Fever Blisters                                                 Yes or No

Epilepsy or Seizures                                       Yes or No

Fainting or Dizzy Spells                                 Yes or No

Nervous Disorders                                          Yes or No       

if yes, Type:________________________________

Glaucoma                                                        Yes or No

Cancer                                                             Yes or No

if yes, what type: ____________________________

Leukemia                                                         Yes or No

if yes, what type:_____________________________

Chemotherapy                                                 Yes or No

if yes, Date:_________________________________

Cobalt/Radiation Treatments                         Yes or No

if yes, Date:_________________________________

Emphysema                                                    Yes or No

Asthma                                                            Yes or No

if yes, is Inhaler required for dental treatment?______

Hay Fever                                                        Yes or No

Sinus Problems                                               Yes or No

Allergies or Hives                                            Yes or No

Diabetes                                                            Yes or No

if yes,  type:_________________________________

             insulin requirement:_____________________

             oral medication required:_________________

             diet and exercise only:                       Yes or No

Thyroid /Disease (Overactive/Underactive)   Yes or No

if yes, medication taken:_______________________

Ulcers                                                                Yes or No

Cortisone Medication                                      Yes or No

if yes, Oral medication:_________________________

if yes, Injection only, Date: ______________________

if yes, Topical medication only:___________________

Have you taken or are you taking bone density medication?        

                                                                            Yes or No

if yes, circle or list the type of bone density drug:

     Actonel,    Fosamax,    Aredia,    Zometa,   other________

if yes, when, how long, was the bone density drug taken:

______________________________________________

Have you taken bisphosphonate medications for any other purpose?   

                                                                               Yes or No

if yes, list drug, when and how long taken:_______________

Are you pregnant?                                                Yes or No

Are you taking birth control medications?          Yes or No

Are you breast feeding?                                        Yes or No

 Are you allergic or have you reacted adversely to any of the following?

Aspirin                                                                  Yes or No

Tylenol                                                                 Yes or No

Codeine                                                                 Yes or No

Ibuprofen                                                               Yes or No

Latex (Rubber)                                                      Yes or No

Hydrocodone/Vicodin                                           Yes or No

Amoxicillin                                                             Yes or No

Penicillin                                                                  Yes or No

Erythromycin                                                          Yes or No

Clindamycin                                                            Yes or No

Local Anesthetic                                                     Yes or No

Valium                                                                     Yes or No

Sulfa Drugs                                                             Yes or No

Are you aware of being allergic to any other medication or substances? If yes please list:

_______________________________________________________________________ 

_______________________________________________________________________

 _______________________________________________________________________

 Are you taking any medication?                                Yes or No

If yes, please list the medications: ______________________________________________________________________

______________________________________________________________________

 ______________________________________________________________________

 ______________________________________________________________________

 ______________________________________________________________________

 Are you taking any vitamins or herbal supplements?   Yes or No 

If yes, please list any vitamins or nutritional supplements you may be taking:

 _______________________________________________________________________

________________________________________________________________________

 _______________________________________________________________________ 

_______________________________________________________________________ 

________________________________________________________________________

 Please list any other medical or dental information that you feel the doctor should be told:

_________________________________________________________________________

_________________________________________________________________________

 ________________________________________________________________________ 

________________________________________________________________________ 

_________________________________________________________________________

 

I certify that these statements concerning my health are correct to the best of my knowledge:

_________________________________________________________________________

Print name

__________________________________________________________________________

Signature

Date:  ________________

 

Privacy Policy

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPPA), I have certain rights to privacy regarding my protected health information. 

 I understand that the information collected by this office can and will be used to: conduct, plan, and direct, my treatment and follow-up care among the multiple health care providers who may be involved in that treatment directly and indirectly.  Obtain payment from third-party payers (i.e. employers and insurance programs). Conduct normal health care operations such as quality assessments and physician certifications. 

I acknowledge that I may request your “Notice of Privacy Practices” document which contains a more complete description of the uses and disclosures of my health information.  I understand that this organization has the right to change the “Notice of Privacy Practices” informational form from time to time, and that I may contact this organization at any time to obtain a current copy of the “Notice of Privacy Practice”.

Date:__________________

Signed:________________________________________________________________ 

Print Name:_____________________________________________________________

 

Communication Policy

Communication is a very important part of providing quality health care.  In an effort to provide you with timely information regarding your healthy care, we ask that you complete the following:

 We normally contact our patients between 8:00am and 5:00pm. You will be asked to provide the phone number that we should use to contact you during that time period:

(   )____________________________ Home  Work  Cell  Other

 If you are unavailable at the time we contact you, may we leave medical information with another person?     Yes        No

Can we leave a message on an answering machine or with another person while confirming the appointment?    Yes         No 

Date:__________________

 Signed:________________________________________________________________

Print Name:_____________________________________________________________

 

Patient Consent & Expectations for Endodontic Treatment at FVES

  1. I will authorize Dr. Rauschenberger, Dr. Shariff, and any other agents or employees of Fox Valley Endodontic Specialists and such assistants as may be selected by any of them to treat the conditions described to me at my initial treatment or consultation appointment in their office. 
  2. The Procedure(s) necessary to treat the conditions(s) will be explained to me for one or more of the following procedures:  a Root Canal Treatment, an Emergency Treatment Procedure to address pain and/or swelling, a Root Canal Re-treatment Procedure, a Root Canal Surgical Procedure, or a Diagnostic Pain or other Diagnostic Endodontic Evaluation. 
  3. I will be informed of the possible alternative methods of treatment including no treatment at all.
  4. The doctor will explain to me the inherent and potential risks in any treatment plan or procedure.
  5. It will be explained to me that a perfect result is not guaranteed or warranted and cannot be guaranteed or warranted when providing treatment options by humans for the human body.  The expectation or prognosis for a successful treatment will be provided to me according to available scientific evidence and my clinical condition prior to the initiation of the procedure.
  6. I will be given the opportunity to question the doctor concerning the nature of the treatment, the inherent risks of the treatment, and the alternatives to the treatment.   

Date:__________________

Signed:_______________________________________________________

Name printed:__________________________________________________