Forms

SECTION A: PATIENT GIVING CONSENT. . . . . . . . Name

Do you think teeth effect your overall health?

Yes

If yes, sre you taking anything to treat such sensitivity?

Lung Disease *

Yes

Arthritis/Grout *

Yes

Excessive Thirst *

Yes

FORM 7: COVID-19 Screening Form

Are you in contact with any confirmed COVID-19 positive patients? *

Yes

Hemophilia *

Yes

Liver Disease *

Yes

Do you require antibiotic before dental treatment (joint replacement)?

Yes

Any other medical information we need to know in order to provide the best care possible?

"A smile is a little thing that makes a big difference!"

Emergency Contact Phone

FORM 2: Insurance Information

Swelling of Limbs *

Yes

FORM 6: Health Information Consent Form

Email:

Do you have heart disease, lung disease, kidney disease, diabetes or any auto-immune disorders? *

Yes

Artificial Heart Disease *

Yes

Soc Security No.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in my medical status. *

Electronic Signature *

Age

FORM 4: Medical Information Part 2

If yes, which doctor prescribed it?

Subscriber Full Name

In case of emergency, who may we contact:

Do you smoke or use tobacco?

Yes

Herpes *

Yes

Address:

What beverages do you drink during the day and how much?

Note: There are a total of 7 forms to complete before you visit our office (unless otherwise directed).

We look forward to seeing you soon!

Primary Physician Phone:

Psychiatric Care *

Yes

AIDS/HIV Positive *

Yes

Are you having shortness of breath or other difficulties breathing? *

Yes

Do you use any other homecare products?

Primary Physician:

Hepatitis A *

Yes

Subscriber SSN:

Insurance Company

Angina *

Yes

Sinus Trouble *

Yes

Convulsions *

Yes

Date *

Preferred Pharmacy:

Heart Murmur *

Yes

FORM 5: Dental Information

Secondary Insurance Co. Phone Number

Congenital Heart Disorder *

Yes

On a scale of 1-10 (with 10 the highest): How important is your dental health to you?

Radiation Treatments *

Yes

Hepatitis B or C *

Yes

Excessive Bleeding *

Yes

If you self-pay you can skip this form and go to Form 3.

Mitral Valve Prolapse *

Yes

Sex

Male

Female

Other (Type preferred pronouns below)

Employer

Tumors or Growths *

Yes

How would you rate your current dental health?

Poor

Fair

Good

Very Good

Relationship to Patient:

Anaphylaxis *

Yes

Is the color of your teeth important to you?

Yes

If this Consent is signed by a personal representative on behalf of the patient:

Secondary Insurance Company

Secondary Insurance ID #

Hay Fever *

Yes

Acid Reflux *

Yes

Last 4 SSN

Do you know of any dental treatment you need?

Yes

Date *

Sickle Cell Disease *

Yes

Anemia *

Yes

Cell Phone

Rheumatism *

Yes

Are you having sensitivity to hot, cold, sweets, or chewing?

Yes

Do you like your smile?

Yes

Heart Attack *

Yes

Date of your last cleaning?

Telephone:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my and other's health. It is my responsibility to inform the dental office of any changes. *

Cancer *

Yes

Recent Weight Loss *

Yes

Tuberculosis *

Yes

Diabetes *

Yes

Chest Pains *

Yes

Birthdate: *

Are you flossing daily?

Yes

Date *

Chemotherapy *

Yes

Subscriber's Birthdate

Any other serious illness not listed above?

When was your last visit to the dentist?

Name (First, Last, Middle Initial): *

Call Us: 315-548-5141

Alzheimer's *

Yes

Low Blood Pressure *

Yes

Electronic Signature *

What do you prefer to be called?:

Stomach Issues *

Yes

Drug Addiction *

Yes

Ulcers *

Yes

How often are you brushing?

Parathyroid Disease *

Yes

Date *

FORM 1: Patient Information

Rheumatic Fever *

Yes

Pain in Jaw Joints *

Yes

Blood Transfusions *

Yes

Frequent Headaches *

Yes

Date *

Have you experienced recent loss of taste or smell? *

Yes

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue? *

Yes

Emphysema *

Yes

Do you have a cough? *

Yes

Leukemia *

Yes

Notable reaction to allergens:

Spina Bifida *

Yes

Blood Disease *

Yes

Marital Status

Married

Single

Divorced

Widowed

Cold Sores *

Yes

Genital Herpes *

Yes

Why did you leave your last dentist?

Breathing Patterns *

Yes

Venereal Disease *

Yes

If you could change anything about your teeth—what would that be?

Repair black fillings

Repair chipped teeth

Replace old caps/crowns that don't match

Make them straighter

Close spaces

Be able to chew better

Smile makeover (comprehensive exam treatment options)

Tonsillitis *

Yes

SECTION B: TO THE PATIENT— PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY. . . . . . . Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. . . . You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting: Kari Durham (315) 548-5141, Fax (315) 548-7627, 10 S Wayne St, Phelps, NY 14532. . . . . . . . . . . . . . . . . . . . Right to Revoke: You will have the right to revoke this Consent at anytime by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations. *

Hives or Rash *

Yes

Electronic Signature *

Secondary Insurance Subscriber Name

As of this week (8/5/21), we as a healthcare facility are required by the CDC to ask you these questions prior to your appointment.

At entry all patients are required to wear a mask or face covering. We ask you to call us from your car for preauthorization and temperature check (per CDC guideline).

What is the most important thing about your dental visit today?

Do you have a fever or felt hot or feverish recently (14-21) days? *

Yes

Heart Trouble/Disease *

Yes

Relation to Patient

What medications do you take? (Or you can provide us with a list of your medications when you arrive at the office)

Bruise Easily *

Yes

Shingles *

Yes

Scarlet Fever *

Yes

FORM 3: Medical Information Part 1

Frequent Cough *

Yes

Date *

Who should we thank for referring you to our practice? *

William S. Woodworth, D.D.S.

Does dental treatment make you nervous? *

Yes

Insurance ID #:

Fainting Spells/Dizziness *

Yes

Address

Thyroid Disease *

Yes

Stroke *

Yes

Heart Pacemaker *

Yes

Do you have, or have you had any of the

following?

Osteoporosis *

Yes

City, state of pharmacy

Date *

Is your age over 60 years old? *

Yes

Are you having any discomfort?

Epilepsy or Siezures *

Yes

Please share the following information with us. We will work together to insure you have a comfortable experience.

Asthma *

Yes

Glacuoma *

Yes

Insurance Co. Phone Number

Do you have, or have you had any of the following? *

Artificial Joint (Knee, Hip, Shoulder etc. . .)

High Blood Pressure

Kidney Problems

Does your employer offer FSA or HAS benefits?

Yes

High Cholesterol *

Yes