Patient Registration
Patient Information:
Mr Mrs Ms Dr Male Female Single Married Divorced Widowed
First Name
Middle
Last Name
Preferred Name(If any)
Address
City
State
Zip Code
Billing Address(If Different)
City
State
Zip Code
Home Phone
Cell Phone
Work Phone
Email
Best time & number to contact you
Date of Birth(mm/dd/yyyy)
Age
Social Security # (For Insurance)
Driver's License #
Contact name & number in case of emergency
How did you hear about us?
~ If you make insurance cards available for us to photo copy you do not need to enter your insurance information ~
Employer of Primary Insurance Holder
Employer Phone of Primary Insurance Holder
Primary Insurance Company
Phone
Policy #
Group #
Employer of Secondary Insurance Holder
Employer Phone of Secondary Insurance Holder
Secondary Insurance Company
Phone
Policy #
Group #
Treatment Coordination
To better coordinate your treatment, please list the professionals you have consulted regarding your present symptoms. Please be sure to list your primary physician and family dentist. Please indicate with a check mark if you want us to send them a report from your visit.
Family Physician
Name
Phone
Please send a report to my Family Physician
Address
City
State
Zip Code
Dentist
Name
Phone
Please send a report to my Dentist
Address
City
State
Zip Code
Chiropractor
Name
Phone
Please send a report to my Chiropractor
Address
City
State
Zip Code
Physical Therapist
Name
Phone
Please send a report to my Physical Therapist
Address
City
State
Zip Code
Ear, Nose & Throat
Name
Phone
Please send a report to my Ear, Nose & Throat
Address
City
State
Zip Code
Cardiologist
Name
Phone
Please send a report to my Cardiologist
Address
City
State
Zip Code
Allergist
Name
Phone
Please send a report to my Allergist
Address
City
State
Zip Code
Neurologist
Name
Phone
Please send a report to my Neurologist
Address
City
State
Zip Code
Psychiatrist or Psychologist
Name
Phone
Please send a report to my Psychiatrist or Psychologist
Address
City
State
Zip Code
Pulmonologist
Name
Phone
Please send a report to my Pulmonologist
Address
City
State
Zip Code
Other (Specialist)
Name
Phone
Please send a report to my Other specialist
Address
City
State
Zip Code
   I understand and agree to have the indicated professionals I have listed above be sent initial information and ongoing updates regarding my diagnoses and treatments.
   I do not wish to have my records sent at this time.
CONSENT FOR TREATMENT & FINANCIAL AGREEMENT

I, the undersigned hereby authorize the Doctor to take radiographs, study models, photographs, records or any other diagnostic aids he/she deems appropriate to and consent the Doctor to employ any such assistance as he/she deems appropriate under the law. I further authorize the release of diagnosis, radiographs, patient records, treatments or examinations rendered: to my insurance company, consulting professionals and others I approve.

I understand that I am personally responsible for payment of all fees for dental services provided in this office for me or my dependents, regardless of insurance coverage. Breach of this responsibility carries the penalty of compensating the practice for any related attorney's and collection fees. Reservations require a great deal of setup and preparation tailored to you and your treatment. Last minute cancellations and missed reservations will be charged $50.00 per half hour scheduled. To avoid this charge, contact our office within 48 hours of your reservation. We do understand, on occasion, last minute things occur. If we both take our commitment to each other seriously, these issues are often avoidable.

I certify that the information given is correct and current. I am aware that it is my responsibility to read and understand my own dental insurance policy, including benefits, limitations and exclusions. I understand that filing of insurance claims is my responsibility and may be provided as a service to me and that any agreement for dental coverage is between my insurance company and myself. I understand that an estimated portion is due at time of service and is estimated according to expected coverage, which may not be disclosed nor guaranteed by my insurance company. I understand my portion may be more if my insurance company does not pay the anticipated amount. I also understand that services are rendered independent of insurance reimbursement. Reservations require payment in full unless approved arrangements have been made. Returned checks will be charged $30. I have also received the Notice of Privacy Practices on page 3.

Mill Creek Dentistry accepts - Cash, Check, Visa, Master Card, Discover, and American Express as forms of payment. Financing is available OAC.

Patient's Signature
Print Name
Date
Medical Health History:
First Name
Last Name
Name of Personal Physician & Office
Office Phone
Rate your overall Health: Poor Fair Good Excellent
              Height
Weight
Select the following drugs you have used at any time:
Fosamax
Didronel
Aredia
Boniva
Zometa
Skelid
Actonel
Bisphosphonate
For Women
Birth Control or Hormones
Pregnant - Delivery Date
Possibly Pregnant
Nursing
Jaw Discomfort - TMJ             No Yes
Please answer Yes or No to the following:
Yes   No
Heart Problems
Chest pain
Shortness of breath
Blood pressure problem
Heart murmur
Heart valve problem
Taking heart medication
Rheumatic fever
Pacemaker
Artificial heart valve
Blood Problems
Frequent nosebleeds
Abnormal bleeding
Blood disease (anemia)
Ever require a blood transfusion
Allergy Problems
Hay fever
Sinus problems
Asthma
Yes   No
Intestinal Problems
Ulcers
Weight gain or loss
Special diet
Constipation/Diarrhea
Kidney or bladder problems
Bone or Joint Problems
Arthritis
Back or neck pain
Joint replacement
Diabetes
Dry mouth or constantly thirsty
Family history of diabetes
If you have diabetes, is it controlled
HA-1C Score Date
Fainting spells, seizures, epilepsy
Stroke(s)
Frequent or severe headaches
Thyroid problems
Yes   No
Physician required premeds
Cancer or Tumor
Tuberculosis/Respiratory disease
Do you drink alcohol?
Do you smoke?
Use recreational drugs
History of alcohol or drug abuse
Jaundice or liver trouble
HIV +/AIDS
Glaucoma
Narrow angle glaucoma
Slow clotting
Do you wear contact lenses
Hempohilia
Hepatitis? Type
Fainting spells
Herpes or other STD
Emphysema
Lung disease or COPD
Please answer the following - if none, write none. You may also bring your pre-made list to our office
Have you ever had surgery?
Yes No
If yes, please list
List ALL medications you CURRENTLY take (OTC and Prescription)
List ANY medications you've taken in the last year not listed above
List ALL allergies (Example: Aspirin, Antibiotics, Latex, Foods)
I certify the information recorded on this medical & dental form is correct. I understand it is my responsibility to notify Distinctive Dentistry of any changes. I understand if I withhold information regarding allergies, medical conditions, medications, or supplements; I agree not to hold Distinctive Dentistry or its employees liable in the event of death or injury.
Patient or Guardian Signature
Print Name
Date
Doctor's Signature
Date
Dental Health Information:
First Name
Last Name
Rate your Dental Health Poor Fair Good Excellent
How do you feel about dental treatment? Relaxed A little uneasy Tense Anxious Very Anxious Major Phobia
Reason for seeking dental care at this time?
Do you have any problems, concerns or pain we need to be aware of?
How often do you brush & floss?    
Brush
Times Per
Floss
Times Per
Date of dental visit?
Date of last dental x-rays?
Previous Dentist
If you could change your smile, what would you change?
Are you interested in seeing yourself with a whiter smile? Yes No
Please answer Yes or No to the following:
Yes   No
Hot/Cold sensitive teeth
Teeth sensitive to sweets
Sore/Bleeding gums
Periodontal Disease
Missing teeth
Toothaches
Offensive/Bad Breath
Consume Coffee/Tea
Sensitive to metals
Unfavorable dental experiences
Yes   No
Grinding/Clinching of teeth
Face/Mouth pain
Clicking/Popping of jaw
Difficulty Opening/Chewing
Unsightly Spaced teeth
Crooked/Tipped teeth
Growth or lesion in your mouth
Swollen glands
Broken filling(s)
Does jaw pain affect daily routine
Yes   No
Cold Sores/Oral Lesions
Catch food between teeth
Discolored teeth
Loose teeth
Chipped or broken teeth
Gag easily
Wear dentures or partials
Is your bite uncomfortable or uneven
Dissatisfied with appearance of your teeth
Do you prefer to save your teeth
Do you have any disease, condition, or concerns not listed previously that you feel we should know about?
If needed, record or bring to our office a list of additional surgeries, current & recent OTC meds, prescriptions, supplements, and allergies:
PREVIOUS DIAGNOSIS: PSG in sleep lab or Home Sleep Study:
PSG HST Not Available
Date:
Physician Name
Sleep Lab:
Facility
Location
AHI #
Sa02: Baseline %
Lowest Oxygen Saturation %
CPAP INTOLERANCE: (Continuous Positive Airway Pressure Device)
If you have attempted treatment with a CPAP device, but were not able to tolerate it please tell us why:
Have not attempted treatment with a CPAP device
Mask leaks
I was unable to get the mask to fit properly
Discomfort caused by the straps and headgear
Disturbed or interrupted sleep caused by the presence of the device
Noise from the device disturbing my sleep and/or bed partner's sleep
CPAP restricted movements during sleep
CPAP does not seem to be effective
Pressure on the upper lip, causing tooth related problems
A latex allergy
Claustrophobic associations
An unconscious need to remove the CPAP apparatus at night
Other:
EPWORTH SLEEPINESS SCALE
Epworth Sleepiness Scale: How likely are you to doze off or fall asleep in the following situations, in contrast to just feeling tired? This refers to your usual way of life in recent times. Even if you have not done some of these things recently, try to work out how they have affected you. Use the following scale to check the most appropriate numuber for each situation. 0=never doze 1=slight chance of dozing 2=moderate chance of dozing 3=high chance of dozing
Sitting & reading
Watching TV
Sitting inactive in a public place (theater, meeting, etc)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting & talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
Score
OUR LEGAL DUTY

We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April of 2003 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make sure the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the top of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
Marketing Health•Related Services: We will not use your health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. A service, copy, and shipping charge may apply to the sending of personal information. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request In writing.} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us at the address / phone numbers above.
We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at our main phone number (425) 225-6334.