American Dental Association
Medical Alert:
Condition:
Premedication:
Allergies:
Anesthesia:
Date:

HEALTH HISTORY FORM

Name:
Home Phone:
Business Phone:
E‐mail:
Address:
City:
State:
Zip Code:
Occupation::
Height:
Weight:
Date of Birth:
Sex:
SS#:
Emergency Contact:
Relationship:
Phone:
If you are completing this form for another person, what is your relationship to that person?

For the following questions, please select whichever applies, your answers are for our records only and will be kept confidential in accordance with applicable laws. Please note that during your initial visit 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.

DENTAL INFORMATION

Yes

No

Don't Know

Do your gums bleed when you brush?
Have you ever had orthodontic (braces) treatment?
Are your teeth sensitive to cold, hot, sweets or pressure?
Do you have earaches or neck pains?
Have you had any periodontal (gum) treatments?
Do you wear removable dental appliances?
Have you had a serious/difficult problem associated with any previous dental treatment?
If yes, explain:
How would you describe your current dental problem?
Date of your last dental exam:
Date of last dental x-rays:
What was done at that time?
How do you feel about the appearance of your teeth?

MEDICAL INFORMATION

Yes

No

Don't Know

If you answer yes to any of the 3 items below, please stop filling the form.

Have you had any of the following diseases or problems?

Active Tuberculosis
Persistent cough greater than a 3 week duration
Cough that produces blood
Are you in good health?
Has there been any change in your general health within the past year?
Are you now under the care of a physician?
If yes, what is/are the condition(s) being treated?
Date of last physical examination:
Physician:
NAME
PHONE
ADDRESS
CITY/STATE
ZIP
NAME
PHONE
ADDRESS
CITY/STATE
ZIP
Have you had any serious illness, operation, or been hospitalized in the past 5 years?
If yes, what was the illness or problem?
Are you allergic to or have you had a reaction to?
Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Latex
Iodine
Hay fever/seasonal
Animals
Food (specify)
Other (specify)
Metals (specify)
To yes responses, specify type of reaction.

Yes

No

Don't Know

Are you taking or have you recently taken any medicine(s) including non-prescription medicine?
If yes, what medicine(s) are you taking?
Prescribed:
Over the counter:
Vitamins, natural or herbal preparations and/or diet supplements:
Are you taking, or have you taken, any diet drugs such Pondimin (fenfluramine), Redux (dexphenfluramine) or phen-fen (fenfluramine-phentermine combination)?
Do you drink alcoholic beverages?
If yes, how much alcohol did you drink in the last 24 hours?
In the past week?
Are you alcohol and/or drug dependent?
If yes, have you received treatment?
Do you use drugs or other substances for recreational purposes?
If yes, please list:
Frequency of use (daily, weekly, etc.):
Number of years of recreational drug use:
Do you use tobacco (smoking, snuff, chew)?
If yes, how interested are you in stopping? (Select one) Very / Somewhat / Not interested
Do you wear contact lenses?
Have you had an orthopedic total joint (hip, knee, elbow, finger) replacement?
If yes, when was this operation done?
If you answered yes to the above question, have you had any complications or difficulties with your prosthetic joint?
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
If yes, what antibiotic and dose?
Name of physician or dentist*:
Phone:

Women Only

Are you or could you be pregnant?
Nursing?
Taking birth control pills or hormonal replacement?

Please select a response to indicate if you have or have not had any of the following diseases or problems.

Abnormal bleeding
AIDS or HIV infection
Anemia
Arthritis
Rheumatoid arthritis
Asthma
Blood transfusion. If yes, date:
Cancer / Chemotherapy / Radiation Treatment
Cardiovascular disease. If yes, specify below:
Angina
Arteriosclerosis
Artificial heart valves
Congenital heart defects
Congestive heart failure
Coronary artery disease
Damaged heart valves
Heart Attack
Heart murmur
High blood pressure
Low blood pressure
Mitrel valve prolapse
Pacemaker
Rheumatic heart disease / Rheumatic fever
Chest pain upon exertion
Chronic pain
Disease, drug, or radiation-induced immunosurpression
Diabetes. If yes, specify below:
Type I (Insulin dependent)
Type I (Insulin dependent)
Dry Mouth
Eating disorder. If yes, specify:
Epilepsy
Fainting spells or seizures
Gastrointestinal disease
G.E. Reflux/persistent heartburn
Glaucoma
Hemophilia
Hepatitis, jaundice or liver disease
Recurrent Infections
If yes, indicate type of infection:
Kidney problems
Mental health disorders. If yes, specify:
Malnutrition
Night sweats
Neurological disorders. If yes, specify:
Osteoporosis
Persistent swollen glands in neck Respiratory problems. If yes, specify below:
Emphysema
Bronchitis, etc.
Severe headaches / migraines
Severe or rapid weight loss
Sexually transmitted disease
Sinus trouble
Sleep disorder
Sores or ulcers in the mouth
Stroke
Systemic lupus erythematosus
Tuberculosis
Thyroid problems
Ulcers
Excessive urination
Do you have any disease, condition, or problem not listed above that you think I should know about?
Please explain:

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. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her 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.

Signature of Patient/Guardian

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Date:

FOR COMPLETION BY DENTIST

Comments on patient interview concerning health history:
Significant findings from questionnaire or oral interview:
Dental management considerations:

Health History Update: On a regular basis the patient should be questioned about any medical history changes, date and comments notated, along with signature.

Date:
Comment:
Signature of Patient/Guardian

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Date:
Comment:
Signature of Dentist

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Patient Information

Patient Name:
Email:
Occupation:
Marital status:
Employer Address
Spouse Name
DOB
SS#
Whom may we thank for referring you?

Dental Insurance and/or Account Responsibility

Who is responsible for this account?
Relationship to patient
Ins. Co
Group #
Ins. Co address
Is patient covered by an additional insurance? Y / N
Subscriber's Name:
DOB
SS #
Relationship to patient
Ins. Co
Group #
Ins. Co address

ASSIGNMENT AND RELEASE

I, the undersigned certify that I (or my dependent) have insurance coverage with and assign directly to Dr. Herremans 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 hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Responsible Party Signature

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Relationship
Date

Phone Numbers

Cell
Home
Work
Best time and place to reach you
Do you prefer to be contacted by:
Emergency Contact
Name
Relationship
Phone Number: C / H / W

Office Policies

Welcome to the office of Tamara J. Herremans D.D.S, P.C. We feel it is important to inform you of our policies prior to you seeing the Doctor.

We will bill all insurance claims as a courtesy to our patients. Any claims not paid by insurance within 90 days will be turned over to patient for reimbursement. The ultimate responsibility for payment of charges is the patient’s, regardless of the type of insurance a patient has. Insurance reimbursement is a contract between the patient and the insurance carrier.

We request you pay your copay and non-covered charges at the time of service unless previous arrangements have been made. We accept cash, checks, Visa, MasterCard, American Express and Discover. Any balances not paid by insurance will be assessed an interest charge after 60 days. Any delinquent accounts older than 90 days will be turned over to collection.

Once a patient is sent to collections, they will be asked to choose another Dentist.

We will attempt to give our patients a reminder call the business day prior to their appointment. We request that if you have to change your appointment you do so 24 hours in advance as a courtesy to us and other patients who want to be seen. Leaving a message on the answering service does not constitute notice when we do not have time to fill the appointment. Patients who do not cancel or reschedule at least 24 hours in advance will be charged $45/hour scheduled, there will also be a $45 charge for patient who no-show for an appointment. Patient who no-show or cancel 3 times will be asked to seek care elsewhere.

Patient’s requesting a copy of their records must do so in writing. There will be a nominal charge to copy the records, based on the size of the patient’s file.

Patients will be seen for the type of treatment and diagnostic appointment scheduled only. If additional treatment and/or diagnostics are required, the patient may be requested to return for another visit.

We ask that all paperwork required be filled out prior to seeing the Doctor. The patient must have a current ID card complete with claim mailing address. Please verify that Dr. Herremans is listed as a provider of that you are able to go out of network. If Dr. Herremans is not listed as a provider, the patient is responsible for payment at the time of service.

IT IS THE PATIENT’S RESPONSIBILITY TO KNOW THEIR INSURANCE BENEFITS

PATIENT SIGNATURE

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Email

Tamara J Herremans, D.D.S.,P.C.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

*You May Refuse to Sign This Acknowledgement* 

I, , have received a copy of this office’s Notice of Privacy Practices.

Please Print Name
Signature

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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
Communication barriers prohibited obtaining the acknowledgement
An emergency situation prevented us from obtaining acknowledgement
Other (Please Specify) 

TRUTH IN LENDING, EXPLANATION OF LATE CHARGES AND FINANCE CHARGES

Account Info
Account Name
Address 

LATE CHARGE: If your minimum payment is not received by the due date, you may be assessed a late payment charge. The amount of the late charge to be assessed is that maximum amount authorized under the laws of the state of your domicile. In most states, the late charge will be $5.00 or 5% of the past due minimum payment, whichever is greater, with a maximum of $20.00, excluding Montana which is zero.

FINANCE CHARGE: A FINANCE CHARGE is imposed on those charges not paid in full within 30160/90/120/150 days of the date you were first billed for the , charges. The balance on which any FINANCE CHARGE is computed is determined by totaling the charges not paid within the time period shown below on the front of yotir billing statement.

The FINANCE CHARGE is a periodic rate of 1.25% (1% in Washington - .58% in Michigan - .66% in Kentucky - .83% in Missouri) per month. (An ANNUAL PERCENTAGE RATt of 15% - 12% in Washington - 7% in tlichigan - 8% in Kentucky - 10% in Missouri). The FINANCE CHARGE is computed by multiplying the balance on which the FINANCE CHARGE is computed by the periodic rate shown above. There is a $1.00 minimum FINANCE CHARGE (500 minimum in Minnesota).

YOUR BILLING RIGHTS UNDER THE FAIR CREDIT BILLING ACT

If you think you have been billed incorrectly, or if you need more information about a transaction on your bill, write to us on a separate sheet at First Pacific Corporation, PO Box 3000, Salem, OR 97302. We must hear from you no later than 60, days after we have sent you the first' bill on which the error or problem appeared.. You may telephone us at 1-800-574-7064, but doing so will not preserve your rights.

In your letter, please include the following information:

  • Your name and account number.
  • The dollar amount of the suspected error.
  • Describe the error and explain, if you can, why you believe there is an error. If you need more information, describe the item you are not sure about.

YOUR RIGHTS AND OUR RESPONSIBILITIES AFTER WE RECEIVE YOUR WRITTEN NOTICE

  • We must acknowledge your letter within 30 days, unless we have corrected the error by then. Within 90 days, we must either correct or explain why we believe -the error was correct.
  • After we receive your letter, we cannot try to collect any amount you question, or report you as delinquent. We can continue to bill you for the amount in question; including finance charges and we can apply any unpaid amount against your credit limit. You do not have to pay any questioned amount while we are investigating, but you are still obligated to pay the parts of your bill that are not in question.
  • If we find that we made a mistake on your bill, you will not have to pay any finance charges related to any questioned amount. If we didn't make a mistake, you may have to pay finance charges, and you will have to make up any missed payments on the questioned amount. In either case, we will send - you a statement of the amount you owe and the date that it is due.
  • If you fail to pay the amount that we think you owe, we may report you as delinquent. However, if our explanation does not satisfy you and you write to us within 10 days telling us that you still refuse to pay, we must tell anyone we report you to that you have a question about your bill. And we must tell you the name of anyone we reported you to. When the matter is finally settled between us, we must tell anyone we report you to that it has been settled.
  • If we don't follow these rules, we can't collect the first $50.00 of the questioned amount even if your bill was correct.
  • Your continued use of this account constitutes your acceptante of the above stated conditions.
Signature

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Date

1 have reviewed the fallowing treatment plan and fees. I agree to be responsible for all charges for dental services and material not paid by my dental benefits plan, unless the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges.

To the extent permitted under applicable law, I authorize release of any information relating to this claim.

I hereby authorize payment of the dental benefits otherwise payable to me directly to the below named dental entity.

A photocopy of this document may act as an original.

Dental Entity Name

Signature of Insured

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Today's Date