PATIENT REGISTRATION AND MEDICAL HISTORY Date Home Phone Cell Phone Patient Patient Last Name First Name Initial Preferred Name Street Address City State Zip Email Address Sex M F Age Birth Date Single Married Widowed Separated Divorced Employed by Occupation Business Address Business Phone Spouse/Parent Name Spouse/Parent Birthdate Spouse/Parent Employed by Occupation Business Address Business Phone Who is responsible for this account? Relationship to Patient Social Security # Spouse/Parent's Social Security # Name of Dental Insurance Co. Group # Phone # Name of Insured Relationship to Patient Birthdate Social Security # In case of emergency. who should be notified? Phone Whom may we thank for referring you?   MEDICAL HISTORY Physician's Name Date of Last Physical Have you ever had any of the following? (Check All boxes either YES or NO): Yes No Yes No Yes No Yes No Asthma Artificial Joint Allergies to Medicine or Drugs HIV/AIDS or other lmmunosuppressive Disorders Mitral Valve Prolapse Diabetes Allergies to Penicillin Stroke Rheumatic Fever Respiratory Disease Allergies to Tetracycline Ulcer Pacemaker Glaucoma General Allergies Venereal Disease Latex Allergy Kidney Disease Heart Murmur Chemical Dependency Excessive Bleeding Epilepsy Mental Disorders Dizziness Heart Problems Headaches Blood Disease Thyroid Problems High Blood Pressure Hepatitis, Jaundice or Liver Disease Hemophilia History of Tobacco use Low Blood Pressure Blood Thinners Arthritis Do you snore? Circulatory Problems Cancer Tuberculosis Has anyone ever stated that you stop breathing or gasp during sleep? Radiation Treatment Psychiatric Care Swollen Neck Glands Do you wake up and feel refreshed? Artificial Heart Valves Allergies to Anesthetics Sinus Problems Are you aware of grinding or clenching your teeth? Do you have any drug allergies or have you ever had an adverse reaction to any medication? If so, what Have you ever been told that you need to be Pre-Medicated? Yes No Have you ever responded adversely to medical or dental treatment? Are you taking any medication at this time? Yes No If so, what Have you ever taken any of the group of drugs collectively referred to as "fen-phen"? These include combinations of lonimin. Adipex, Fastin(brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine). Yes No Are you under the care of a physician? Yes No For what conditions? Have you been admitted to a hospital or needed emergency care during the past two years? Yes No (WOMEN) Do you suspect that you are pregnant? Yes No Due Date Are you nursing? Yes No Are you currently taking birth control pills? Yes No (certain medications interfere with oral contraceptives) Is there anything else we should know about your medical history? The above information is accurate and complete to the best of my knowledge. Since a change in medical condition or medications can effect dental treatment, I understand the importance of, and agree to any changes at any subsequent appointment. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form. Signature of Patient, Parent or Guardian Date Doctor's Signature ___________________ Date _____________ CONSENT FOR SERVICES Patient Name: I voluntarily and knowingly request and consent to the services, treatments and/or procedures recommended by Dr. Edward Magida and to all diagnostic methods deemed appropriate by the dentist which may include, but not be limited to, X-rays, study models, imagery, and other aides. I authorize the dentist to perform all such services, treatments and/or procedures and to utilize all such diagnostic methods. Further, I acknowledge and understand that the dentist may engage the assistance of others in performing such services, treatments and /or procedures and in utilizing such diagnostic methods. I understand that the practice of dentistry is not an exact science and I acknowledge that no guarantees have been made to me concerning the results of the series, treatments, procedures and/or diagnostic methods that have been recommended. I also understand that the use of anesthesia carries with it significant risks that have been explained to me. I understand and acknowledge that I am fully and completely responsible for the payment of all costs associated with the services, treatments, procedures and/or diagnostic methods performed and utilized by the dentist and others. I acknowledge that an insurance coverage or managed care benefit that I may have is based on a contract between my insurance company or managed care company and me, my spouse and/or my employer. The dentist is not a party to the contract and the services, treatments, procedures and/or diagnostic methods are provided to me. Therefore, I acknowledge that I am fully responsible for the payment of all sums owed to the dentist for the services, treatments, procedures and/or diagnostic methods provided to me. As a courtesy to me, the dental office will bill my insurance company or managed care company and I acknowledge that I will remain liable for any and all amounts not paid by the insurance company or managed care company for any reason (including but not limited to the insurance company or managed care company declining coverage after initially approving it) or if the insurance company or managed care company fails for any reason to reimburse the dentist within 30 days after being billed by the dentist. I acknowledge that it is my responsibility to provide the dentist with my current insurance or managed care information and any changes thereto. All returned checks will be subject to a returned check fee based on bank charges. Any account balances that remain unpaid for 60 days from the date of service shall accrue interest at the current rate and may be referred to a collection company or attorney. In the event this occurs, I understand that I will be liable for collection costs. Further, in the event any unpaid account balance is referred to an attorney for collection, I agree also to be responsible for all costs and reasonable attorney's fees incurred in connection therewith. I consent to the dentist's use and disclosure of my health information to my insurance company or managed care company and any agent thereof. I hereby assign to the dentist all of the insurance and managed care benefits due to me for the services, treatments, procedures and/or diagnostic methods provided to me, and I authorize my insurance company and/or managed care company to make payment directly to the dentist for the costs associated therewith. I further consent to be contacted by the dentist, any agent of the dental office or any collection agency (or agent thereof) or attorney to whom an unpaid account balance has been assigned or referred by mail at any address that I provide to the dental office and/or by facsimile, email or phone number (whether a cell phone or landline) at any facsimile number, email address or phone number (whether a cell phone or landline) that I provide to the dental office or any agent of the dental office. I understand that any fee estimate quoted is only an estimate and will be honored for six months. I also give the office permission to use my photographs of my teeth for educational or promotional purposed and release any right to present or future compensation in connection with the use of said photographs. Signature Patient/Parent/Guardian Date Guardian/Responsible Party Name NEWTOWN DENTAL CARE.P.C. ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** Click here for a copy of our Notice of Pricay Practices I clicked the link above and have received a copy of this office's Notice of Privacy Practices. Name Signature Date For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please Specify) © 2002 American Dental Association All Rights Reserved Reproduction and use of this form by dentists and their staff is permitted Any other use, cuplicaton on Contribution of this form by any other party requires the prior written approval of the American Dental Association This Form is educational only, does not constitute legal advice, and covers only lederal, not state, law (August 14, 2002). EPWORTH SLEEPINESS SCALE Name Date: EPWORTH SLEEPINESS SCALE In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations? Use the following scale to choose the most appropriate number for each situation: 0 = Would never doze 1 = Slight chance of dozing 2 = Moderate chance of dozing 3 = High chance of dozing SITUATION Sitting and reading Watching Television Sitting inactive in a public place (i.e. theater) As a car passenger for an hour without a break Lying down to rest in the afternoon Sitting and talking to someone Sitting quietly after lunch without alcohol In a car, while stopping for a few minutes in traffic TOTAL SCORE A score of 6 or greater indicates the possibility of a sleep breathing disorder Dental Practice Offers Advanced Oral Cancer Screening VELscope Device Helps Dental Practices Respond to Recent Growth in Incidence of Oral Cancer Newtown Dental Care has incorporated the VELscope Oral Cancer Screening System into its dental practice. Oral cancer strikes three times as many victims as cervical cancer. It is one of the few types of cancer that has not seen a significant reduction in incidence over the past thirty years, and recent research has shown a strong association with Human Papilloma Virus (HPV), which can be sexually transmitted. For this reason, many oral health care professionals now believe that all individuals over the age of 18 should have at least an annual comprehensive oral examination, and ideally at every dental hygiene visit. The FDA and Health Canada recently cleared the VELscope System for assisting dentists and hygienists in discovering cancerous or precancerous growths that may not be apparent to the naked eye. A screening with the VELscope System adds only one or two minutes to a conventional examination, is completely free of any pain or discomfort, and is affordably priced. More and more insurance companies are covering the cost of the screening. Oral cancer is typically discovered in late stages, when the five-year survival rate is only 22%. If detected in early stages, however, the five-year survival rate is 80% or higher. The VELscope System can also help discover abnormal growths before they become cancerous. According to Dr. Magida of Newtown Dental Care, "We have always conducted an annual comprehensive oral cancer screening for all of our patients, but now the VELscope System will help us see things we might have missed previously. By detecting potential problems earlier, we will be providing our patients with the best health care currently available". For more information regarding the VELscope System, visit www.velscope.com, or call Newtown Dental Care at 215-968-7787 with any questions and to schedule an appointment. Yes. I authorize the clinician to perform the Velscope exam along with the standard oral cancer examination. I accept financial responsibility for this enhanced examination. Name: Signature Date: NO. I would prefer not to have the Velscope exam at this time. Name: Signature Date: Please enter code above in the field below.