Patient Paperwork Form Patient Information Location —Please choose an option—MarysvilleAuburn DENTAL INSURANCE INFORMATION (PRIMARY) DENTAL INSURANCE INFORMATION (SECONDARY) I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the named denturist or dental entity. Dental History Have you ever had serious trouble during previous dental treatments? YesNo Have you ever had sores on your lips or mouth that are slow to heal? YesNo Are you allergic to latex? YesNo Are you a smoker/tobacco user? YesNo Are you dissatisfied with the appearance of your teeth? YesNo Do you have difficulty in chewing your food? YesNo Have you ever had injuries to your face or jaw? YesNo Do your jaws “pop” or “lock” when opening your mouth wide? YesNo Do you have pain or discomfort now? YesNo Do you wear dentures/partials? YesNo Do you sleep with your denture? YesNo Patient Medical History Do you have or have you had any of the following? Please check all that apply High Blood PressureHeart MurmurLiver DiseaseRadiation TherapyLow Blood PressureHeart AttackCancerRecent Weight LossEpilepsy / ConvulsionsRheumatic FeverArthritisRespiratory ProblemsLeukemiaSwollen AnklesFibromyalgiaHepatitisDiabetesFainting / SeizuresChest PainsHerpesKidney DiseaseAsthmaEasily WindedJoint Replacement or ImplantAIDS or HIV InfectionAnginaStrokeHeart DiseaseEmphysemaHay fever / AllergiesStomach Troubles / UlcersCardiac PacemakerGlaucomaTuberculosis I fully understand that I am using the services of a Denturist, not a Dentist. I understand that a Denturist does not diagnose, evaluate or treat diseases or malfunctions of the oral cavity, and I should see a dentist or physician if such services are required. Informed Consent I understand that removable prosthetic appliances (Partials, Dentures, Flippers and Nesbit's) include risks and possible failures associated with such dental treatment. I agree to assume those risks and possible failures associated with, but not limited to, the following: (even though the utmost care and diligence is exercised in preparation for, and fabrication of, prosthetic appliances, there is the possibility of failure with patients not adapting to them): Failure of full dentures: there are many variables which may contribute to this possibility, such as: (a) gum tissues which cannot bear the pressures placed upon them resulting in excessive tenderness and sore spots; (b) jaw ridges which may not provide adequate support and/or retention; (c) musculature in the tongue, floor of the mouth, cheeks, etc., which may not adapt to and be able to accommodate the artificial appliances; (d) excessive gagging reflexes; (e) excessive saliva or excessive dryness of mouth; (f) general psychological and/or physical problems interfering with success. Failure of partial dentures: Many variables may contribute to unsuccessful utilizing of partial dentures (removable bridges). The variables may include those problems related to failure of full dentures, in addition to: (a) natural teeth to which partial dentures are anchored (called abutment teeth) may become tender, sore, and/or mobile; (b) abutment teeth may decay or erode around the clasps or attachments; (c) tissues supporting the abutment teeth may fail. Breakage: Due to the types of materials which are necessary in the construction of these appliances, breakage may occur even though the materials used were not defective. Factors which may contribute to breakage are: (a) chewing on foods or objects which are excessively hard; (b) gum tissue shrinkage which causes excessive pressures to be exerted unevenly on the dentures; (c) cracks which may be unnoticeable and which occurred previously from causes such as those mentioned in (a) and (b); or the dentures having being dropped or damaged previously. The above may also cause extensive denture tooth wear or chipping. Loose Dentures: Full dentures normally become looser when there are changes in the supporting gum tissues. Dentures themselves do not change unless subjected to extreme heat or dryness. When dentures become "loose", relining the dentures may be necessary. Normally, it is necessary to charge for relining dentures. Partial dentures become loose for the listed reasons in addition to clasps or other attachments loosening. Sometimes dentures feel loose for other reasons (see paragraph 1). Allergies to dental materials: Very infrequently, the oral tissues may exhibit allergic symptoms to the materials used in the construction of either partial dentures or full dentures, over which we have no control. Failure of supporting teeth and/or soft tissue: Natural teeth supporting partials may fail due to decay; excessive trauma; gum tissue or bony tissue problems. This may necessitate extraction. The supporting soft tissues may fail due to many problems including poor dental or general health. It is the patient's responsibility to seek attention when problems occur and do not lessen in a reasonable amount of time; also, to be examined regularly to evaluate the dentures, condition of the gums, and the patient's oral health. INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the nature and purpose of artificial dentures and have been given alternative treatment options and have received answers to my satisfaction. I do voluntarily assume any and all possible problems and risks, including risk of substantial harm, if any, which may be associated with any phase of this treatment in hopes of obtaining the desired potential results, which may or may not be achieved. No guarantees or promises have been made to me concerning the results relating to my ability to utilize artificial dentures successfully nor to their longevity. The fee(s) for this service have been explained to me and are satisfactory. By signing this form, I freely give my consent to authorize my Clinician to render the treatment necessary or advisable to my dental condition(s). Acknowledgement Of Privacy Practices My Signature confirms that I have been informed of my rights to privacy regarding my protected health information under the Health Insurance Portability and Accountability Act 1996 (HIPAA). I understand that this information can and will be used to: Provide and coordinate my treatment among a number of health care providers who may be involved in the treatment directly and indirectly. Obtain payment from third-party payers for my health care services. Conduct normal health care operations such as quality assessment and improvement activities. I have been informed of my dental provider's Notice of Privacy Practices containing a more complete description of the uses and disclosures of my protected health information. I have been given the right to review and receive a copy of such Notice of Privacy Practices. I understand that my dental provider has the right to change the Notice of Privacy Practices and that I may contact this office at the address above to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations, and I understand that you are not required to agree to my requested restrictions, but if you do agree, then you are bound to abide by such restrictions.
