Microsoft word - patient health history pg1.doc

Patient Name______________________________________Date______________________________
Medical Physician’s Name & Phone___________________________________________________________

Please answer the following health questions as completely as possible (circle YES or NO)
1. Do you consider yourself to be in good health?
2. Are you now or have you been under a physicians care within the past year? 3. Do you take any medications, including birth control pills? 5. Have you ever been told you have a heart murmur? 6. Do you require antibiotic pre-medication for a heart condition, artificial valve, or 8. Have you ever been diagnosed as being HIV positive or having AIDS? 9. Have you ever had hepatitis or liver disease? 10. Circle if you have ever had any of the following: Rheumatic Fever Asthma Rheumatism Arthritis Tuberculosis Venereal Disease Heart Attack Immune System Disease Blood Disorder Other Disease- 11. Circle if you have ever had any unusual reaction or if you are allergic to: Penicillin Aspirin Acetaminophen Ibuprofen Codeine Barbiturates 12. Have you ever had a severe reaction to dental treatment or local anesthetics? 14. Do you have any other allergies? If YES please explain: 15. Have you ever had a nervous breakdown or undergone psychiatric treatment? 16. Have you ever received counseling for excessive use of alcohol and/or drugs? 18. How long ago did you see your last dentist? Name of previous dentist?_____________________ 19. Do you have or have you ever had bleeding or sensitive gums? • If YES, have you seen your physician or cardiologist for a cardiac evaluation? 21. Have you taken Bisphosphonates such as Fosamax, Actonel, Boniva, Aredia, Zometa,
Snoring and Sleep Apnea Screening
Has anyone reported that you choke or gasp for air while sleeping?
Dental information
Are you currently in pain?
Do you have any pain in or near your ears? Do you habitually clench your teeth during the day or night? Do you have any present dental complaints? Are you happy with the appearance of your teeth/gums/smile? • If NO, what don’t you like about your smile?________________________________________________ Would you like to discuss how to WHITEN your teeth? Would you like to discuss enhancing the appearance of your smile? Health Questionnaire Acknowledgement
I certify that the answers to the health questions are accurate and correct to the best
of my knowledge. Since a change of medical condition or medications can affect dental
treatment, I understand the importance of and agree to notify the dentist of any
changes at any subsequent appointments.

I authorize Dr. Stephen F. Johansen and/or assistants, as he may designate, to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor individual for which I have responsibility, including arrangement and/or administration of any sedative, analgesic, therapeutic, and/or other pharmaceutical agent(s), including those related to restorative, palliative, therapeutic, or surgical treatments. I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to, bruising, hematoma, cardiac stimulation, temporarily or rarely permanent numbness, and muscle soreness. I understand that occasionally needles break and may require surgical retrieval. I request and consent to all dental procedures which my dental conditions or those of my dependants may require, and I understand that procedures in dental surgery, diagnosis, and treatment are not an exact science and no guarantees as to the outcome of my treatments will be offered only that Dr. Stephen F. Johansen will exercise his professional expertise and ability in my best interests according to his best judgment. In consenting to any oral surgery I understand that possible hazards may include, but are not limited to: pain, swelling, bruising, infection, tingling, or numbness of the lips, tongue, gums, and/or face, loss or damage to other teeth or restorations, root or tooth into the sinus, oral antral fistula, maxillary sinusitis, possible mandibular fracture, and postoperative hemorrhage and discomfort. Adverse reactions to materials, medicines, anesthetics, and procedures are possible in dentistry, possibly resulting in, but not limited to, pulpal irritation, root canal treatment, loss of teeth, necrosis, infection, pain, anaphylactic shock, and intestinal or systemic upset, and voluntarily assume the possible risks. I consent to the fees charges for services by Dr. Stephen F. Johansen and they are satisfactory to me. In essence, I accept Dr. Stephen F. Johansen as my dentist and understand that he will exercise all his professional knowledge to the best of his ability. I do voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with general preventative and operative treatment procedures in hope of obtaining the potential desired results, which may or may not be achieved, for my benefit or the benefit of my minor child or ward. I acknowledge that the nature and purpose of the foregoing procedures have been explained to me if necessary and I have been given the opportunity to ask questions. _______________________________________________________________________________
Patient Signature (Parent or Legal Guardian)

I have reviewed my original health history above and certify that it is accurate except for
changes indicated below:

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Date Changes

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Who may we thank for referring you to our office? ____________________________________________
Patient Information
Patients Name________________________________ Preferred Name_________________ Male/Female Birth Date ________________ Age______ SS# _____________________ Marital Status S M D O Address __________________________________ City/State ___________ , _________ Zip __________ Home Phone _________________ Employer _________________________ Work Phone_____________ Cell or other phone ________________ Email Address________________ DL#_____________________ Person Responsible for Account ______________________________ Relationship __________________ Birth Date ________________ Age______ SS# _____________________ DL#_____________________ Address __________________________________ City/State ___________ , _________ Zip __________ Phone _________________ Employer _____________________________ Work phone ______________ In Case of an Emergency: (that does not live with you)
Name of Nearest Relative or Friend___________________________________ Phone________________ Address ______________________________ City / State ________ , _______ Zip __________________ Primary Dental Insurance Information
Insured Name ____________________________ ID# _____________________ Birth Date ___________ Insurance Company________________________ Group or Policy Number_________________________ Ins. Address _____________________________ City / State _________ , ___________ Zip __________ Insurance Phone __________________________ Insurance Fax (if available)_______________________ Employer _______________________________ Employer Phone Number_________________________ Secondary Dental Insurance (complete only if covered by two insurance companies)
Insured Name ____________________________ ID# _____________________ Birth Date ___________ Insurance Company________________________ Group or Policy Number_________________________ Ins. Address _____________________________ City / State _________ , ___________ Zip __________ Insurance Phone __________________________ Insurance Fax (if available)_______________________ Employer _______________________________ Employer Phone Number_________________________ PAYMENT AGREEMENT
In accordance with the Federal Truth-In-Lending Act which requires all doctors to give their patients information in connection with the extension of credit, please be advised of the following policy which applies to this office. The responsible party agrees to: Pay the doctor at the time services are rendered. I understand that Dr. Johansen will submit an insurance claim on my behalf
but all charges incurred are ultimately my responsibility. A finance charge of 1.5% will be added to all accounts over 60 days old.
If a collection agency is required I agree to pay collection fees, up to 40%, which will be added to my outstanding balance.
Responsible Person Signature _____________________________________________ Date _________________________

Please understand we are desirous to extend care to you and
work with you and any insurance coverage you may have.

• Professional services are rendered to the patient, and not to the insurance company. Thus the insurance company is responsible to the patients, and the patient is responsible to the doctor. We cannot render service on the assumption that the charges will be paid for by an insurance company. • Unfortunately, insurance benefits will almost always be less than anticipated. Please understand the amount of benefits to be derived under your particular policy is a pre-determined arrangement between your employer and the insurance company; we are unable to increase benefits beyond that which this agreement allows. • For your convenience we will estimate the portion of your total fee that your insurance company will cover. This is only an estimate. After insurance benefits, you are responsible for any uncovered portion of total fee. I authorize my insurance company to make payment directly to the doctor for services rendered and agree to pay any uncovered balance. I herby authorize release of information for insurance purposes. • If you desire to know exactly what your insurance coverage will be, prior to treatment, then we can pre-authorize our benefits. However, this delays treatment 4-6 weeks, waiting for the insurance company to respond. • A finance charge of 1.5% per month will be added to your bill if payment has not been received within 60 days. This will allow adequate time for you to see that your insurance benefits have been paid to your satisfaction. • Should collection become necessary, the responsible party agrees to pay all collection fees, up to 40% and reasonable attorney fees.
Thank you for your understanding in this matter.

Dr. Stephen F. Johansen, D.D.S, PC

Office Policies:

Patients that do not have dental insurance, payment in full is
expected on the day of service. We offer zero interest financing
through Care Credit.
Patients with dental insurance, the responsible party will pay the
patient portion and any deductible on the day of service. The
insurance will be billed as a courtesy, however please be aware

that if the insurance does not pay within 90 days, payment in full
is expected.
Patients that have a scheduled appointment and need to cancel
must do so 24 hours prior to the appointment or a $75.00
cancellation fee will apply. The reason for this policy is that we
do not routinely double book patients. Therefore same day
cancellations do not leave us enough time to fill the appointment

leaving the doctor’s time open. This is particularly important
with the hygienist’s schedule because she is never double booked

and your appointment time is specifically reserved for you. If we
are to maintain a “non assembly line” dental office and continue
to treat one patient at a time, it is imperative that patients keep

their appointments or leave us an adequate amount of time to
schedule another patient.

There is a $25.00 processing fee for any returned checks.
The responsible party agrees to pay all collection fees, up to 40%
and all attorney fees and court costs associated with collecting
for services rendered.
At times photographs of dental procedures may be taken for
demonstration, advertisement, patient records and insurance
purposes. By signing below I allow Dr. Stephen Johansen to use

any photographs of me for the aforementioned purposes. At no
time will my identity be revealed without my consent.


Signature Date



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