Informed Consent for Dental Treatment

  1. I hereby authorize Shelby Pines Family Dentistry to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by the dentist to make a thorough diagnosis of your dental needs.
  2. Upon such diagnosis, I authorize Shelby Pines Family Dentistry to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
  3. I hereby authorize Shelby Pines Family Dentistry to administer anesthetic, sedative and or nitrous oxide (laughing gas) as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications associated with this.
  4. I agree to be responsible for payment of all services rendered on my behalf or my dependents behalf. I understand that payment is due at the time of service unless other payment arrange-ments have been made. In the event that payment is not made I understand there may be a late charge added to my account. I also agree to pay for all collection costs if additional collection is required.

It is very important that you provide your dentist with accurate information before, during and after treat-ment. It is equally important that you follow your dentists advice and recommendations regarding medica-tion, pre and post treatment instruction, referrals to other dentists or specialist, and return for scheduled appointment. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.

The patient is a very important part of the treatment team. In addition to complying with the instructions given to you by this oce, it is important to report any problems or complications you experience so they can be assessed by your dentist.

In accordance with the Health Insurance Portability and Accountability Act (HIPAA), this information will tell you about the ways in which we may use and disclose medical/dental information about you. We also describe your rights and certain obligations we have regarding the use and disclosure of your personal, identiable health and medical information.

**Please feel free to review the “PRIVACY POLICIES” booklet our oce follows. The booklet will be located in the reception area next to the check in desk.

*By typing your name in the signature box above, you are certifying that the information included in this form is true to the best of your knowledge. Typing your full name in the signature above is the legal equivalent of your written signature, and will stand as such in all legal matters.
*If patient representative signs above, please describe the relationship to the patient:

DENTAL HISTORY

Referred by
How would you rate the condition of your mouth?
Previous Dentist
Date of most recent dental exam
Date of most recent treatment
I routinely see my dentist every
WHAT IS YOUR IMMEDIATE CONCERN?
PLEASE ANSWER YES OR NO TO THE FOLLOWING:
YES
NO
PERSONAL HISTORY
1. Are you fearful of dental treatment? Scale of 1 to 10 (very)
2. Have you had an unfavorable dental experience?
3. Have you ever had complications from past dental treatment?
4. Have you ever had trouble getting numb or reactions to local anesthetic?
5. Did you ever have braces, orthodontic treatment or had your bite adjusted?
6. Have you had any teeth removed?
SMILE CHARACTERISTICS
7. Is there anything about the appearance of your teeth that you would like to change?
8. Have you ever whitened (bleached) your teeth?
9. Are you self conscious about your teeth?
10. Have you been disappointed with the appearance of previous dental work?
BITE AND JAW JOINT
11. Do you have any problems chewing certain foods?
12. Have your teeth changed in the last 5 years, become shorter, thinner or worn?
13. Are your teeth crowding or developing spaces?
14. Do you feel like you clench or grind your teeth?
15. Do you have problems with your jaw joint? (pain, sounds, limited opening, locking, popping)
16. Do you have tension headaches or sore teeth?
17. Do you wear or have you ever worn a bite guard?
TOOTH STRUCTURE
18. Have you had any cavities within the past 3 years?
19. Do you have a dry mouth?
20. Are any teeth sensitive to hot, cold, biting or sweets?
21. Have you ever had a toothache, cracked filling, broken, chipped or cracked tooth?
GUM AND BONE
22. Have you ever been diagnosed or treated for periodontal (gum) disease?
23. Have you ever experienced gum recession
24. Is there anyone with a history of periodontal disease in your family?
25. Do your gums bleed when brushing, flossing or eating?
26. Are your teeth becoming loose?
27. Have you ever noticed an unpleasant taste or odor in your mouth?
28. Would you like to keep all your teeth for life?
*By typing your name in the signature box above, you are certifying that the information included in this form is true to the best of your knowledge. Typing your full name in the signature above is the legal equivalent of your written signature, and will stand as such in all legal matters.
Shelby Pines Cosmetic & Family Dentistry

MEDICAL HISTORY

PATIENT NAME
Birth Date
Today’s Date
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
Are you under a physician’s care now?
Have you ever been hospitalized or had a major operations?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet
Do you use tobacco?
Do you use controlled substances?
If yes, please explain:
If yes, please explain:
If yes, please explain:
If yes, please explain:
Women: Are you
Pregnant/Trying to get pregnant?
Taking oral contraceptives?
Nursing?
Are you allergic to any of the following?
If yes, please explain:
Do you have, or have you had, any of the following?
AIDS/HIV Postive
Alzheimer’s Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problem
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disorder
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy or Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Cholesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidneys Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Disease
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsillitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice
Have you ever had any serious illness not listed above?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.
SIGNATURE OF PATIENT, PARENT, or GUARDIAN
DATE
Shelby Pines Cosmetic & Family Dentistry

PATIENT REGISTRATION

ID:
Chart ID:
First Name:
Last Name:
Middle Initial:
Patient Is:
Preferred Name:
Responsible Party (if someone other than the patient)
First Name:
Last Name:
Middle Initial:
Address:
Address2:
City, State, Zip:
Home Phone:
Work Phone:
Ext
Cellular
Birth Date:
Soc Sec
Drivers Lic:
Patient Information
Address:
Address2:
City, State, Zip:
Home Phone:
Work Phone:
Ext
Cellular
Birth Date:
Age:
Soc Sec
Drivers Lic:
Address:
Section 2
Employment Status:
Student Status:
Medicaid ID:
Employer ID:
Carrier ID:
Pref. Dentist
Pref. Pharmacy:
Pref. Hyg.:
Section 3
Emergency Contact:
Contact Number:
Primary Insurance Information
Name of Insured:
Employment Status:
Insured Soc. Sec
Insured Birth Date:
Employer:
Address:
Address2:
City, State, Zip:
Ins. Company:
Address:
Address2:
City, State, Zip:
Rem. Benefits:
.00
Rem. Deduct:
.00
Secondary Insurance Information
Name of Insured:
Employment Status:
Insured Soc. Sec
Insured Birth Date:
Employer:
Address:
Address2:
City, State, Zip:
Ins. Company:
Address:
Address2:
City, State, Zip: