Existing Patient Update Form

Email Address

Today's Date

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

First Name

Last Name

Middle Initial

Address

City

State

Zip

If you are completing this form for another person, what is your relationship to that person?

Your Name

Relationship

Home Phone

Cell Phone

Best time to contact you?

Emergency Contact

Emergency Contact Name

Emergency Contact Phone

What is the relationship to the emergency contact?

Insurance Information

If your insurance information has changed, please complete the following:

Insurance Company

Insurance Group #

Insurance Plan #

Effective Date

Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following:

Local anesthetics

Yes

Aspirin

Yes

Penicillin or other antibiotics

Yes

Barbiturates, sedatives, or sleeping pills

Yes

Sulfa drugs

Yes

Codeine or other narcotics

Yes

Metals

Yes

Latex (rubber)

Yes

Iodine

Yes

Hay fever / seasonal

Yes

Animals

Yes

Food / Other

Yes

If yes, please specify

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

Heart murmur

Yes

Mitral valve prolapse

Yes

Artificial heart valves

Yes

Rheumatic fever

Yes

Cardiovascular disease

Yes

Angina

Yes

Arteriosclerosis

Yes

Congestive heart failure

Yes

Coronary artery disease

Yes

Damaged heart valves

Yes

Heart attack

Yes

Low blood pressure

Yes

High blood pressure

Yes

Congenital heart defects

Yes

Pacemaker

Yes

Rheumatic heart disease

Yes

Abnormal bleeding

Yes

Anemia

Yes

Blood transfusion

Yes

If yes, date

Hemophilia

Yes

AIDS or HIV infection

Yes

Arthritis

Yes

Autoimmune disease

Yes

Rheumatoid arthritis

Yes

Systematic lupus erythematosus

Yes

Asthma

Yes

Bronchitis

Yes

Emphysema

Yes

Sinus trouble

Yes

Tuberculosis

Yes

Cancer / Chemotherapy / Radiation treatment

Yes

Chest pain upon exertion

Yes

Chronic pain

Yes

Diabetes type I or type II

Yes

Eating disorder

Yes

Malnutrition

Yes

Gastrointestinal disease

Yes

GE Reflux / persistent heartburn

Yes

Ulcers

Yes

Thyroid problems

Yes

Stroke

Yes

Glaucoma

Yes

Hepatitis, jaundice, or liver disease

Yes

Epilepsy

Yes

Fainting spells or seizures

Yes

Neurological disorders

Yes

If yes, please specify

Gag Reflex Sensitivity

Yes

Sleep disorder

Yes

Mental health disorders

Yes

If yes, please specify

Recurrent infections

Yes

If yes, type of infection

Kidney problems

Yes

Night sweats

Yes

Osteoporosis

Yes

Persistent swollen glands in neck

Yes

Severe headaches / migraines

Yes

Severe / rapid weight loss

Yes

STDs / STIs

Yes

Excessive urination

Yes

ADD

Yes

ADHD

Yes

Sensory Processing Disorder

Yes

Oral Sensory Sensitivity

Yes

Has a physician or previous doctor recommended that you take antibiotics prior to your treatment?

Yes

Do you have any disease, condition, or problem not listed above that you think we should know about?

Yes

If yes, please explain

Please list any current medications

Please list any current supplements

Pharmacy Information

Pharmacy Name

Pharmacy Phone

Pharmacy Address

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

Download Printable Version

Patient Acknowledgement and Consent Form

📍 4300 E. Court St. P.O. Box 90125 Burton, MI 48509

📞 (810) 742-5140

📧 parkdentalfrontdesk@gmail.com

Effective April 14, 2003, the new federal law known as the Health Insurance Portability and Accounting Act of 1996 (HIPAA) requires that this office comply with certain rules regarding the privacy of your information that we have collected and will collect in the future.

To comply with one of HIPAA's requirements we have copies of our Notice of Privacy Practices in the office for your review. This Notice of Privacy Practices contains the information that HIPAA requires us to disclose regarding our privacy practices.

Existing Michigan law requires us to first obtain your written consent prior to disclosing any of your information except for your disclosures in connections with: a defense to a claim challenging our professional competence; a review entity's functions; a claim for payment of fees; a third-party payer's examination of our records; a court order as part of a criminal investigation; an identification of a dead body; a licensure investigation; or a child abuse/neglect investigation.

From time to time it may be necessary for us to make disclosures of your information in connection with our treatment. For example, we may make a referral to or consult with another dentist or other health care professional, provide a specimen to a laboratory for testing or otherwise make disclosures of your information in connection with providing or coordinating your treatment.

Patient Acknowledgement

I acknowledge that I have today received and/or had access to a copy of the Notice of Privacy Practices. I consent to your disclosure of my information, which you deem necessary in connection with my treatment. I understand that such disclosures may not be of the type listed above.

Patient/Parent Signature

Patient Name (Please Print)

I am also signing for my minor children (please list names)

I also give consent for my treatment to be discussed with the following individuals (spouse, parent, adult child, caregiver, etc.)

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue

Download Printable Version

Authorization

📍 4300 E. Court St. P.O. Box 90125 Burton, MI 48509

📞 (810) 742-5140

📧 parkdentalfrontdesk@gmail.com

I hereby certify that I have read and understood the previous information and that it is accurate and true to the best of my knowledge. I acknowledge that providing incorrect/inaccurate information has the potential of being hazardous to my health. If I ever have a change in my health, I will inform the office at my next dental appointment without fail.

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

I also authorize Park Dental Center, Linda M Park, to use my likeness in a photograph and/or x-rays in all publications including but not limited to printed and digital publications and advertisements. I acknowledge that I will receive no compensation for the use of my likeness.

I authorize the dentist to release any information including the diagnosis and records of treatment or examination for myself and my dependent(s) to third-party insurance carriers, payors, and/or healthcare practitioners. I authorize my insurance carrier to submit payment directly to the dentist or dental practice to be applied directly to any outstanding balance on my account.

I understand that I am financially responsible for any outstanding balance for services provided that are not fully covered by insurance, and I may be billed for this remaining balance. I consent and agree to be financially responsible for payment of all services rendered on my behalf or on the behalf of my dependents (if any) and/or anyone covered on my insurance.

I have been informed and agree that I will be charged a $50.00 fee for appointments cancelled with less than 24 hours' notice.

Signature of patient, parent, or guardian

Printed Name

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Continue