PLEASE COMPLETE THE FOLLOWING CONFIDENTIAL INFORMATION IF THIS APPOINTMENT IS FOR YOU START HERE DATE FIRST LAST NAME M.I. PREFERS TO BE CALLED BY ADDRESS CITY STATE ZIP HOME PHONE NO. FAX CELL EMAIL BIRTHDATE AGE MALE FEMALE MARRIED SINGLE DIVORCED WIDOWED SOCIAL SECURITY NO. IF THIS APPOINTMENT IS FOR YOUR CHILD START HERE DATE LAST NAME FIRST M.I. ADDRESS CITY STATE ZIP HOME PHONE NO. BIRTHDATE AGE MALE FEMALE SCHOOL GRADE SOCIAL SECURITY NO. PATIENT REGISTRATION DENTAL INSURANCE PRIMARY CARRIER INSURANCE COMPANY GROUP NO EMPLOYER NAME INSURED'S NAME DATE OF BIRTH RELATIONSHIP TO PATIENT INSURED'S I.D. NO INSURED'S SOCIAL SECURITY NO. SECONDARY CARRIER INSURANCE COMPANY GROUP NO EMPLOYER NAME INSURED'S NAME DATE OF BIRTH RELATIONSHIPTO PATIENT INSURED'S I.D. NO INSURED'S SOCIAL SECURITY NO. GETTING TO KNOW YOU IS ANOTHER MEMBER OF YOUR FAMILY OR RELATIVE A PATIENT AT OUR OFFICE? NAME: RELATIONSHIP YOU WERE REFERRED TO US BY NAME: PERSON TO CONTACT FOR EMERGENCY NAME: CELL NUMBER HOME NUMBER ADDRESS CITY STATE ZIP ACCOUNT INFORMATION PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT NAME RELATIONSHIPTO PATIENT SOCIAL SECURITY NO. ADDRESS CITY STATE ZIP PHONE NO. YOU NAME OCCUPATION EMPLOYER'S NAME ADDRESS CITY PHONE NO. FAX NO. YOUR SPOUSE NAME OCCUPATION EMPLOYER'S NAME ADDRESS CITY PHONE NO. FAX NO. CONSENT FOR TREATMENT 1.I hereby authorize doctor or designated staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of (name of patient) 's dental needs. 2.Upon such diagnosis, I authorize doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care 3.I agree to the use of anesthetics, sedatives and other medication 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. 4.I give consent to the doctor's or designated staff's use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed and that a notice fully outlining the protection of my personal health information is available. 5.I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed upon dates, I understand that a 1-1/2% late charge (18% APR) may be added to my account. If required, I also understand a check of my credit history may be made. Patient's Signature Date Witness Parent/Responsible Party's Signature Relationship to Patient Wycliff Family Dentistry, LLC Eaglesoft Medical History Patient Name: Birth Date: Date Created: Are you under a physician's care now? YES NO If yes Have you ever been hospitalized or had a major operation? YES NO If yes Have you ever had a serious head or neck injury? YES NO If yes Are you taking any medications, pills, or drugs? YES NO If yes Do you take, or have you taken, Phen-Fen or Redux? YES NO If yes Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? YES NO If yes Are you on a special diet? YES NO Do you use tobacco? YES NO Do you use controlled substances? YES NO If yes Women: Are you... Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives? Are you allergic to any of the following? Aspirin Metal Penicillin Latex Codeine Sulfa Drugs Acrylic Local Anesthetics Other? If yes Do you have, or have you had, any of the following? Yes No AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial HeartValve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problems Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder convulsions Cortisone Medicine Yes No 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 Yes No Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral Valve Prolapse Osteoporosis Pain in jaw Joints Parathyroid Disease Psychiatric Care Radiation treatments Yes No Recent WeightLoss 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 had any serious illness not listed above? YES NO If yes Comments: To the best of my knowledge, the questions on this form have been accurately answered. I understand that provding incorrect information can be dangerous to my (or patient's) health. It ts my responsibly to inform the dental office of any changes in medical status. Signature of Patient, Parent or Guardian: Date: Dental History Patient Name: Patient Account No.: Medical Alert: Welcome! So that we may provide you with the best possible care please complete both sides of this medical/dental history form. All information is completely confidential. What is the reason for your visit today? Date of Last Dental Visit Last Dental Cleaning Last Full Mouth X-rays What was done at your last dental visit? Previous Dentist's Name Telephone Address State Zip How often do you have dental examinations? How often do you brush your teeth? How often do you floss? Have you ever used or are currently using topical fluoride? Yes No What other dental aids do you use? (Interplak, toothpick, etc.) Do you have any dental problems now? Yes No If yes, please describe: Are any of your teeth sensitive to: Yes No Hot or cold? Sweets? Biting or Chewing? Have you noticed any mouth odors or bad tastes? Do you frequently get cold sores, blisters or any other oral lesions? Do your gums bleed or hurt? Have your parents experienced gum disease or tooth loss? Have you noticed any loose teeth or change in your bite? Does food tend to become caught in between your teeth? If yes, where Do you: Yes No Clench or grind your teeth while awake or asleep? Bite your lips or cheeks regularly? Hold foreign objects with your teeth? (pencils, pipe, etc.) Mouth breathe while awake or asleep? Mouth breathe while awake or asleep? Snore or have any other sleeping disorders? Smoke/chew tobacco or use other tobacco products? Have you ever had: Yes No Orthodontic treatment? Oral Surgery? Periodontal treatment? Your teeth ground or the bite adjusted? A bite plate or mouth guard? A serious injury to the mouth or head? Please describe, including cause Have you experienced: Yes No Clicking or popping of the jaw? Pain? (joint, ear, side of face) Difficulty in opening or closing the mouth? Difficulty in chewing on either side of the mouth? Headaches, neck-aches or shoulder aches? Sore muscles (neck, shoulders)? Yes No Are you satisfied with your teeth's appearance? Would you like to replace your silver fillings? Would you like to keep all of your teeth all of your life? Do you feel nervous about having dental treatment? Yes No If yes, Please describe Have you ever had an upsetting dental experience? Yes No If yes, Please describe Have you ever been told to take a pre-medication prior to dental treatment? Yes No Is there anything else about having dental treatment that you would like us to know? Yes No If yes, please describe Wycliff Family Dentistry, LLC HIPAA NOTICE OF PRVACY PRACTICES ("Notice") THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. The Dental Practice Covered By This Notice This Notice describes the privacy practices of Wycliff Family Dentistry, LLC. ("Dental Practice"). "We" and "our" means the Dental Practice. "You" and "your" means our patient. How to Contact Us/Our Privacy Official If you have any questions or would like further information about this Notice, you can either write or call the Privacy Official for our Dental Practice: Dental Practice Name: Wycliff Family Dentistry, LLC Privacy Official for Dental Practice: Cynthia Elliott Dental Practice mailing address: 10400 W. 103rd St., Suite 21, Overland Park, KS 66214 Dental Practice email address: wyclifffamilydentistry@gmail.com Dental Practice phone number: (913) 722-0610 Information Covered By This Notice This Notice applies to health information about you that we create or receive and that identifies you. This Notice tells you about the ways we may use and disclose your health information. It also describes your rights and certain obligations we have with respect to your health information. We are required by law to: • Maintain the privacy of your health information; • Give you this Notice of our legal duties and privacy practices with respect to that information; and • Abide by the terms of our Notice that is currently in effect. Our Use and Disclose of Your Health Information Without Your Written Authorization Common Reasons for Our Use and Disclosure of Patient Health Information Treatment. We will use your health information to provide you with dental treatment or services, such as cleaning or examining your teeth or performing dental procedures. We may disclose health information about you to dental specialists, physicians, or other health care professionals involved in your care. Payment. We may use and disclose your health information to obtain payment from health plans and insurers for the care that we provide to you. Health Care Operations. We may use and disclose health information about you in connection with health care operations necessary to run our practice, including review of our treatment and services, training, evaluating the performance of our staff and health care professionals, quality assurance financial or billing audits, legal matters, and business planning and development Appointment Reminders. We may use or disclose your health information about you when contacting you to remind you of a dental appointment. We may contact you by using a postcard, letter, voicemail, or email. Treatment Alternatives and Health-Related Benefits and Services. We may use and disclose your health information to tell you about treatment options or alternatives or health-related benefits and services that may be of interest to you. Disclosure to Family Members and Friends. We may disclose your health information to a family member or friend who is involved with your care or payment for your care if you do not object or, if you are not present, we believe it is in your best interest to do so. Less Common Reasons for Use and Disclosure of Patient Health Information The following uses and disclosures occur infrequently and may never apply to you. Disclosures Required by Law. We may use or disclose patient health information to the extent we are required by law to do so. For example, we are required to disclose patient health information to the U.S. Department of Health and Human Services so that it can investigate complaints or determine our compliance with HIPAA. Public Health Activities. We may disclose patient health information for public health information for public health activities and purposes, which include: preventing or controlling disease, injury or disability reporting births or deaths; reporting child abuse or neglect; reporting adverse reactions to medications or foods; reporting product defects; enabling product recalls; and notifying a person who may have been exposed to a disease or may be at risk for contracting or spreading a disease or condition. Victims of Abuse, Neglect or Domestic Violence. We may disclose health information to the appropriate government authority about a patient whom we believe is a victim of abuse, neglect or domestic violence. Health Oversight Activities. We may disclose patient health information to a health oversight agency for activities necessary for the government to provide appropriate oversight of the health care system, certain government benefit programs and compliance with certain civil rights laws. Lawsuits and Legal Actions. We may disclose patient health information in response to (i) a court or administrative order or (ii) a subpoena, discovery request, or other lawful process that is not ordered by a court if efforts have been made to notify the patient or to obtain an order protecting the information requested. Law Enforcement Purposes. We may disclose patient health information to a law enforcement official for a law enforcement purposes, such as to identify or locate a suspect, material witness or missing person or to alert law enforcement of a crime. Coroners, Medical Examiners and Funeral Directors. We may disclose patient health information to a coroner, medical examiner or funeral director to allow them to carry out their duties. Organ, Eye and Tissue Donation. We may use or disclose patient health information to organ procurement organizations or others that obtain, bank or transplant cadaveric organs, eyes or tissue for donation and transplant. Research Purposes. We may use or disclose patient health information for research purposes pursuant to patient authorization waiver approval by an Institutional Review Board or Privacy Board. Serious Threat to Health or Safety. We may use or disclose patient health information if we believe it is necessary to do so to prevent or lessen a serious threat to anyone's health or safety. Specialized Government Functions. We may disclose patient health information to the military (domestic or foreign) about its members or veterans, for national security and protective services for the President or other heads of state, to the government for security clearance reviews. And to a jail or prison about its inmates. Workers Compensation. We may disclose patient health information to comply with workers' compensation laws or similar programs that provide benefits for work-related injuries or illness. Your Written Authorization for Any Other Use or Disclosure of Your Health Information We will make other uses and disclosures of health information not discussed in this Notice only with your written authorization. You may revoke that authorization at any time in writing. Upon receipt of the written revocation, we will stop using or disclosing your health information for the reasons covered by the authorization going forward. Your Rights with Respect to Your Health Information. You have the following rights with respect to certain health information that we have about you (information in a Designated Record Set as defined by HIPAA). To exercise any of these rights, you must submit a written request to our Privacy Official listed on the first page of this Notice. Access. You may request to review or request a copy of your health information. We may deny your request under certain circumstances. You will receive written notice of a denial and can appeal it. We will provide a copy of your health information in a format you request if it is readily producible. If not readily producible, we will provide it in a hard copy format or other format that is mutually agreeable. If your health information is included in an Electronic Health Record, you have the right to obtain a copy of it in an electronic format and to direct us to send it to the person or entity you designate in an electronic format. We may charge a reasonable fee to cover our cost to provide you with copies of your health information. Amend. If you believe that your health information is incorrect or incomplete, you may request that we amend it. We may deny your request under certain circumstances. You will receive health information you believe is incorrect or incomplete. Restrict Use and Disclosure. You may request that we restrict uses of your health information to carry out treatment, payment, or health care operations or to your family member or friend involved in your care or the payment for your care. We may not (and are not required to) agree to your requested restrictions, with one exception. If you pay out of your pocket in full for a service you receive from us and you request that we not submit the claim for this service to your health insurer or health plan for reimbursement, we must honor that request. Confidential Communications: Alternative Means, Alternative Locations. You may request to receive communications of health information by alternative means or at an alternative location. We will accommodate a request if it is reasonable and you indicate that communication by regular means could endanger you. When you submit a written request to the Privacy Official listed on the first page of this Notice, you need to provide an alternative method of contactor alternative method of contact or alternative address and indicate how payment for services will be handled Accounting of Disclosures. You have a right to receive an accounting of disclosures of your health information for the six years prior to the date that the accounting is requested except for disclosures to carry out treatment, payment, health care operations (and certain other exceptions as provided by HIPAA). The first accounting we provide in any 12-month period will be without charge to you. We will charge a reasonable fee to cover the cost for each subsequent request for an accounting within the same 12-month period. We will notify you in advance of this fee and you may choose to modify or withdraw your request at that time. Receive a Paper Copy of this Notice. You may have the right to a paper copy of this Notice. You may ask us to give you a paper copy of the Notice at any time (even if you have agreed to receive the Notice electronically). To obtain a paper copy, ask the Privacy Official. We Have the Right to Change Our Privacy Practices and This Notice We reserve the right to change the terms of this Notice at any time. Any change will apply to the health information we have about you or create or receive in the future. We will promptly revise the Notice when there is a material change to the uses or disclosures, individual's rights, our legal duties, or other privacy practices discussed in this Notice. We will post the revised Notice on our website (if applicable) and in our office and will provide a copy of it to you on request. The effective date of this Notice (including any updates) is in the top right-hand corner of the Notice. To Make Privacy Complaints If you have any complaints about your privacy rights or how your health information has been used or disclosed, you may file a complaint with us by contacting our Privacy Official listed on the first page of this Notice. You may also file a written complaint with the U.S. Department of Health and Human Services Office for Civil Rights. The privacy of your health information is important to us. We will not retaliate against you in any way if you choose to file a complaint. Wycliff Family Dentistry, LLC ACKNOWLEDGEMENT OF RECEIPT OF HIPAA NOTICE OF PRVACY PRACTICES ("Acknowledgement") I acknowledge that I have received a copy of this Dental Practice's HIPAA Notice of Privacy Practices. Patient Name Patient Signature Date OR Signature of Personal Representative Authority of Personal Representative to Sign for Patient (Check One) Parent Guardian Power of Attorney Other Please Note: It is your right to refuse to sign this Acknowledgement Dental Office Use Only I tried to obtain written Acknowledgement by the individual noted above of receipt of our Notice of Privacy Practices, but it could not be obtained because: ___ An emergency prevented us from obtaining acknowledgement. ___ A communication barrier prevented us from obtaining acknowledgement. ___ The individual was unwilling to sign. ___ Other________________________________________________________________________________ ________________________________________ ________________________________________ Staff Member Signature Date Please enter code above in the field below.