Patient Registration

First Name *

Last Name *

Dental Interview

Who may we thank for recommending us to you?

How can I help you today? *

Have you had difficulty going numb at dental visits in the past? *

Yes

When was your last dental visit? *

What was your last dental visit for? *

What's most important to you in the DENTAL CARE you receive? (list 2 rules) *

What needs to happen while you are here to achieve this care? (list your 2 rules) *

Why did you leave your last dentist?

Is there anything about going to the dentist that you dislike or makes you uncomfortable?

What else would you like to share with the doctor about your care/and or needs?

Do you LIKE your smile? *

Yes

If I could show you an easy and safe way to lighten your teeth, would you be interested? *

Yes

Today's dentistry has made great advances. We can instantly straighten upper or lower teeth in just 2 visits. Does this interest you at all? *

Yes

If you could wave a magic wand and change your teeth or smile, what would you change? *

Do you have pain in any teeth currently? *

Yes

Do you think you might have some cavities now? *

Yes

Patient Information

SS/HIC/Patient ID #

Address *

City *

State *

Zip *

Email *

Sex *

Age *

Date of birth *

Marital Status *

Occupation

Patient Employer/School

Employer/School Address

Employer/School Phone

Spouse's Name

Spouse's Birthdate

Spouse's SS #

Spouse's Employer

Dental Insurance

Primary Insurance *

Yes

If yes, fill below

Who is responsible for this account?

Relationship to Patient

Insurance Company

Group A

Is patient covered by additional insurance?

Yes

Subscriber's Name

Birthdate

SS #

Relationship to Patient

Insurance Company

Group #

Assignment and Release

I certify that I, and/or my dependent(s), have insurance coverage with the above-named Insurance Company(ies) and assign directly to Dr. Toni Sartini all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or Personal Representative *

Clear

Please type name of Patient, Parent, Guardian or Personal Representative *

Date *

Relationship to Patient

Phone Numbers & Contact Information

Cell Phone *

Home

Work

Spouse's Work

Best time and place to reach you

IN CASE OF EMERGENCY, CONTACT: (Specify someone who does not live in your household)

Name *

Relationship *

Home Phone

Work Phone

Dental History

Reason for today's visit *

Former Dentist *

Former Dentist City/State *

Date of last dental visit *

Date of last dental X-rays *

Please indicate with "Yes" or "No" if you have had any of the following:

Bad breath *

Yes

Bleeding Gums *

Yes

Blisters on lips or mouth *

Yes

Burning sensation on tongue *

Yes

Chew on one side of mouth *

Yes

Cigarette, pipe, or cigar smoking *

Yes

Clicking or popping jaw *

Yes

Dry mouth *

Yes

Fingernail biting *

Yes

Food collection between the teeth *

Yes

Foreign objects *

Yes

Grinding teeth *

Yes

Gums swollen or tender *

Yes

Jaw pain or tiredness *

Yes

Lip or cheek biting *

Yes

Loose teeth or broken fillings *

Yes

Mouth breathing *

Yes

Mouth pain, brushing *

Yes

Orthodontic treatment *

Yes

Pain around ear *

Yes

Periodontal treatment *

Yes

Sensitivity to cold *

Yes

Sensitivity to heat *

Yes

Sensitivity to sweets *

Yes

Sensitivity when biting *

Yes

Sores or growths in your mouth *

Yes

How often do you floss? *

How often do you brush? *

Health History

Physician's Name *

Date of Last Visit *

Have you ever taken any of the group of drugs collectively referred to as "fen-phen?" These include combinations of Ionimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramin) and Redux (dexfenfluramine). *

Yes

Medical History

Please indicate with "Yes" or "No" if you have had any of the following:

AIDS/HIV Positive *

Yes

Anemia *

Yes

Arthritis, Rheumatism *

Yes

Artificial Joint *

Yes

Asthma *

Yes

Back Problems *

Yes

Bleeding abnormally, with extractions or surgery *

Yes

Blood Disease *

Yes

Cancer *

Yes

Chemical Dependency *

Yes

Chemotherapy *

Yes

Circulatory Problems *

Yes

Congenital Heart Lesions *

Yes

Cortisone Treatments *

Yes

Cough, persistent or bloody *

Yes

Diabetes *

Yes

Emphysema *

Yes

Epilepsy *

Yes

Fainting or dizziness *

Yes

Glaucoma *

Yes

Headaches *

Yes

Heart Murmur *

Yes

Heart Problems *

Yes

Hepatitis *

Yes

If yes, what type

High Blood Pressure *

Yes

Jaundice *

Yes

Jaw Pain *

Yes

Kidney Disease *

Yes

Liver Disease *

Yes

Low Blood Pressure *

Yes

Mitral Valve Prolapse *

Yes

Nervous Problems *

Yes

Pacemaker *

Yes

Psychiatric Care *

Yes

Radiation Treatment *

Yes

Respiratory Disease *

Yes

Rheumatic Fever *

Yes

Scarlet Fever *

Yes

Shortness of Breath *

Yes

Sinus Trouble *

Yes

Skin Rash *

Yes

Special Diet *

Yes

Stroke *

Yes

Swollen Feet or Ankles *

Yes

Thyroid Problems *

Yes

Tonsillitis *

Yes

Tuberculosis *

Yes

Tumor or growth on head or neck *

Yes

Venereal Disease *

Yes

Weight Loss, unexplained *

Yes

Do you wear contact lenses? *

Yes

Implants

Do you have implants (including cosmetic) joints, pins, plates?

Yes

If yes, when placed?

Told to take antibiotic?

Yes

Female Patients

Are you a female patient?

Yes

Are you pregnant?

Yes

Pregnancy due date

Are you nursing?

Yes

Are you taking birth control pills?

Yes

Medications

List any medications you are currently taking and the correlating diagnosis

Pharmacy Name

Phone

Allergies

Other

Appointment Cancellation

I understand that I will be charged a fee of $75 if I fail to give Dr. Sartini's staff 24 hours notice for the cancellation for an appointment.

Patient Signature *

Date *

Consent for Dental Treatment and Acknowledgment of Receipt of Information

At the office of Dr. Toni Sartini, 845 St. NE, Palmayra, IN 47164

State Law requires us to obtain your consent for dental treatment. Please ask us about anything you do not understand. We are ready to answer any of your questions or explain anything you do not understand.

Any alternative to the recommended treatments, including no treatment, have been explained to me. In general terms the contemplated dental treatment is/are:

\tFillings with resin material

\tCrowns, inlays/onlays, bridges

\tProphylaxis(cleaning)/periodontal therapy

\tPost and/or cores

\tImplants/Crown or dentures

\tGingival removal

\tTeeth whitening

\tAny necessary xrays

\tLaser usage

\tDentures/partials

There are risks associated with any dental treatment. This includes the administration of any local or general anesthetics agent, analgesic agents(s) to produce conscious sedations, and/or premedication prior to dental care being rendered. Some of the risks/complications are, but are not limit to, the following:

\tInfection

\tBleeding

\tFailure of wound to heal

\tParasthesia or numbness of tongue, and/or mouth, and/or face

\tInjury to adjacent structures

\tAllergic reaction to drugs bacterial endocarditis

\tInjuries to adjacent teeth and/or hard or soft tissues

\tDeath (in rare instances)

\tInstrument breakage

\tLoss of teeth

Additional oral surgery, hospitalization and/or further treatment may be required in the even of any complication(s).

Acknowledgement

I acknowledge that I have read this consent form, or that it has been read to me, and that I understand the information contained on this consent form. I was given adequate opportunity to ask any questions and all questions that were asked were answered to my satisfaction.

I hereby authorize and direct the dentist and/or associate, hygienist, and/or assistants of their choice to perform the diagnostic, surgical or dental treatment recommended. This consent form will remain valid unless revoked by me in writing.

Date *

Signature of patient or guardian *

Clear

Acknowledgement of Receipt of Notice of Privacy Practices.

- You may refuse to Sign this Acknowledgement -

I, [ PATIENT NAME ], have received a copy of this office's Notice of Privacy Practices

Signature *

Clear

Date *

Consent for Use and Disclosure of Health Information

Purpose of Consent: By signing this form, you will consent to our office use and disclosure of your protected health information to carry out treatment, payment and healthcare operations.

Signature *

Clear

Date *

Patient Advisory and Acknowledgement -- Receiving Dental Treatment During the COVID-19 Pandemic

Dear Patient:

You have come to our office today for a routine dental evaluation and/or treatment that will be done during the COVID-19 pandemic. Please be advised of the following:

While our office complies with State Health Department and the Centers for Disease Control and Prevention infection control guidelines to prevent the spread of COVID-19 virus, we cannot make any guarantees.

Our staff are symptom-free and, to the best of their knowledge, have not been exposed to the virus. However, since we are a place of public accommodation, other persons (including other patients) could be infect, with or without their knowledge.

In order to reduce the risk of spreading COVID-19, we have asked you a number of "screening" questions below. For the safety of our staff, other patients, and yourself, please be truthful and candid in your answers.

Print Name- Patient/Responsible Party *

Signature - Patient/Responsible Party *

Clear

Date *

Patient Screening Questionnaire

Please answer "yes" or "no" to the following questions:

Are you currently awaiting the results of a COVID-19 test? *

Yes

Do you have a fever? *

Yes

Do you have any shortness of breath? *

Yes

Do you have a dry cough? *

Yes

Do you have a runny nose? *

Yes

Do you have a sore throat? *

Yes

Do you have sneezing, watery eyes, and/or sinus pain/pressure that is unusual and not related to seasonal allergies? *

Yes

Have you experienced headaches, fatigue, or weakness? *

Yes

Have you lost your sense of taste and/or smell? *

Yes

Within the last 14 days, have you traveled to any foreign country? *

Yes

Within the last 14 days, have you traveled within the United States? *

Yes

If yes, where?