Admission Form | Hammond & Proctor

Adult Health History
Insurance Information
HIPAA Form

Web Site

Adult Health History

Patient’s Name *

Birthdate

Age

Sex

Male Female

Home Address

City

State

Zip

Home Phone Number

Work Phone

Your Soc. Sec

Status

Single Married Separated Widow

Occupation

Are you a full time student?

Yes No

If patient is minor we need

Mother’s Name

Mother's Birthdate

Father’s Name

Father's Birthdate

Person responsible for account

Your Driver’s License Number

Name of spouse ( or parent if minor)

Your Email Address

Your Cell Number

Spouse’s ( or parent’s) employer

Spouse’s Soc. Sec. #

Work Phone Number

EMERGENCY INFORMATION

Name, Address, & Telephone of a relative not living with you:

How did you hear about our office? Circle all that apply.

Please state reason for this visit?

DENTAL INSURANCE INFORMATION (Primary Carrier)

Insured’s Name

DOB

SS#

Insured’s employer

Insurance Co

Insurance Co Address

Phone #

Group #

Policy #

If you have a dual insurance coverage, complete this for the second coverage.

Yes No

DENTAL HISTORY

Please check any of the following that applies to you:

Sensitivity (hot, cold, sweet)

Yes No

Headaches, earaches, neck or jaw joint pain

Yes No

Mouth ulcers or cold sores

Yes No

Teeth or fillings breaking

Yes No

Bleeding, swollen or irritated gums

Yes No

Loose, tipped or shifting teeth

Yes No

Bad Breath

Yes No

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

Dentures

Yes No

Partial Dentures

Yes No

Braces

Yes No

Gum Treatments

Yes No

Please share the following dates:

Your last cleaning

Your last oral cancer screening

Your last complete X-Rays

Name of Previous Dentist

Previous Dentist City

Previous Dentist State

Phone Number

What is the most important thing to you about your future smile and dental health?

If you could whiten your teeth for a cost anyone could afford, would you do it?

Do you smoke or use chewing tobacco?

How Much?

For how long?

If I could change my smile, I would:

Make my teeth whiter

Make my teeth straighter

Close space

Replace metal fillings with tooth colored restorations

Repair chipped teeth

Replace missing teeth

Replace old crowns that don't match

Have a smile makeover

On a scale of 1 – 10, with 10 being the highest rating:

How important is your dental health to you?

1 2 3 4 5 6 7 8 9 10

Where would you rate your current dental health?

1 2 3 4 5 6 7 8 9 10

Why did you leave your previous dentist?

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

MEDICAL HISTORY

Please check any of the following that applies to you:

Allergies (Seasonal)

Yes No

Anemia

Yes No

Artificial Heart Valve

Yes No

Artificial Joints

Yes No

Asthma

Yes No

Blood Disease

Yes No

Bruise Easily

Yes No

Cancer

Yes No

Excessive Bleeding

Yes No

Glaucoma

Yes No

Heart Conditions

Yes No

Heart Murmur

Yes No

Hepatitis A

Yes No

Hepatitis B

Yes No

Hepatitis C

Yes No

High Blood Pressure

Yes No

Nervousness/Depression

Yes No

Pacemaker

Yes No

Phen Fen (1 month +)

Yes No

Radiation (head/neck)

Yes No

Respiratory Problems

Yes No

Rheumatic Fever

Yes No

Rheumatism

Yes No

Scarlet Fever

Yes No

Ulcers

Yes No

Snoring

Yes No

Sleep Apnea

Yes No

Fatique

Yes No

Migraines

Yes No

Chronic Pain

Yes No

OTHER (please list)

Yes No

Bisphosphonate

Yes No

Chemotherapy

Yes No

HIV/AIDS

Yes No

Seizures

Yes No

For WOMAN Only

Diabetes

Yes No

Dizziness/Fainting

Yes No

Drug Addiction

Yes No

Emphysema

Yes No

Jaundice

Yes No

Kidney Disease

Yes No

Liver Disease

Yes No

Mitral Valve Prolapse

Yes No

Stomach Problems

Yes No

Stroke

Yes No

Thyroid Disease

Yes No

Tuberculosis

Yes No

Birth Control Pills

Yes No

Breast-feeding

Yes No

Pregnant

Yes No

Mos

1-3 3-6 6-9

Do you have an allergy to any of the any of the following?

Aspirin

Yes No

Erythromycin

Yes No

Latex

Yes No

Local Anesthetic

Yes No

Nitrous Oxide

Yes No

Penicillin

Yes No

Codeine

Yes No

Other:

What medications are you currently taking?

Are you under a physician’s care? For what?

Family Physician

Phone Number

Patient Signature (or Parent of Child)

Date

Dentist’s Signature

I consent to the dental practice using my cell phone number to (choose one or both) call or text regarding appointments and to call regarding treatment, insurance and my account. I understand that I can withdraw my consent at any time.

My cell phone number

Insurance Policy

IMPORTANCE OF THE PATIENT AWARENESS REGARDING INSURANCE BENEFITS:

Couch and Hammond Family Dentistry realizes how important insurance benefits are. Please be informed that dental insurance is a contract between you and your insurance company. Our role is to assist you with filing your claim. We are providing the highest quality of care for you and your family regardless of insurance frequencies, limitations and/or restrictions. If you have two insurance policies, be aware not all secondary policies will cover remaining portions. Your insurance mails a copy of an Explanation of Benefits (EOB) to you. Please pay attention to these statements. It is your responsibility to provide us with any future changes in your insurance. If any insurance services have been provided with any other dental office within the existing benefit year, please advise us.

I understand the above information.

FINANCIAL POLICY

In order to provide you with the highest quality care on a sound business practice, we research each insurance policy to the best of our ability and provide our patients the most accurate estimates of fees. Patient, parent, and/or guardian is responsible for the patient portion (copay) on the date of service. This is not your insurance company’s responsibility. We will file all necessary claims to your insurance as a courtesy to you. It is your responsibility to call your insurance company if they have not paid your claim within 45 days from the date of service.
It is your responsibility to complete treatment and follow recommended maintenance schedule. If the treatment and maintenance plans are not followed and/or appointments are missed, adverse results could affect your dental health. If you do not proceed with your treatment plan in a timely manner, further treatment for the involved teeth, supporting tissues, adjacent and opposing teeth, muscles or joints can be affected.

I understand the above information.

APPOINTMENT COMMITMENT

We understand that your time is very valuable. Trying to accommodate every patient’s individual needs and work schedule can be challenging. We make every effort to stay on time so that our patients will not have to wait unnecessarily.
Your appointment is a commitment of time between you and our office. We ask that you make every effort to keep that commitment. We do provide courtesy reminder calls within one week prior to your appointment, or we can email you at your request. A broken appointment, one in which a patient does not call or show up is not acceptable. If you find that you cannot keep your reservation, we do require a minimum notice of 48 business hours. If our office is not notified within the 48 business hours, you will be subject to a $55 late cancellation charge.
We truly appreciate your understanding. Our goal is to be your partner in health and to assist you in keeping your teeth for a lifetime

I understand the above information.

I understand and agree to the aforementioned, and promise to pay any/all remaining balance on my account.

Signature

Date

NOTICE OF PRIVACY PRACTICES

To Our Patients:

This notice describes how health information about you (as a patient of this practice) may be used and disclosed, and
how you can get access to your health information. This is required by the Privacy regulations created as a result of the
health insurance Portability and Accountability Act of 1996 (HIPAA)

Our Commitment To Your Privacy

Our practice is dedicated to maintaining the privacy of your health information.
We are required by law to maintain the confidentiality of your health information.

We realize that these laws are complicated, but we must provide you with the following important information:

Use and Discloser of Your Health Information in Certain Special Circumstances

To public health authorities and health oversight agencies that are authorized by law to collect information.
Lawsuits and similar proceedings in response to a court or administrative order.
If required to do so by a law enforcement Official.
When necessary to reduce or prevent a serious threat to your health and safety of another individual or the
public. We will only make disclosures to a person or organization able to help prevent the threat.
If you are a member of U.S. or foreign forces (including veterans) and if required by the appropriate
authorities.
To federal officials for intelligence and national security activities authorized by law.
To correctional institutions or law enforcement officials if you are an inmate or under the custody of a law
enforcement official.
For Workers Compensation and similar programs.

Your Right Regarding Your Health Information

Communications. You can request that our practice communicate with you about health and related issues in a
particular manner or at a certain location. For instance, you may ask that we contact your home, rather than
work. This may include contacting you by way of non-secured devices, such as answering machines, cellular
phones, pagers, etc. We will accommodate reasonable requests.
You can request a restriction in our use of disclosure of your health information for treatment, payment or
health care operations. Additionally, you have the right to request that we restrict our disclosure of your
information only to certain individuals in our care, such as family members and friends. If we do agree to your
request, we are bound by agreement except when otherwise requested by law, in emergencies, or when the
information is necessary to treat you.
You have the right to inspect and obtain a copy of the health information that may be used to make decisions
about you, including patient medical records and billing records, but not including therapy notes. You must
submit your request in writing to Couch & Hammond Dentistry Partnership. You must provide us with a reason
that supports your request for amendment.
Right to a copy of this notice. You are entitled to receive a copy of this notice of Privacy Practices. You may
ask us to give you a copy of this Notice at any time. To obtain a copy of this notice, contact our front desk
receptionist.
Right to file a complaint. If you believe your privacy rights have been violated, you may file a complaint with
our practice or with the secretary of the Department of Health and Human Services. To file a complaint with
our practice, contact Couch & Hammond Dentistry Partnership.
Right to provide authorization for other uses and disclosures. Our practice will obtain your written authorization
for uses and disclosures that are not identified by this notice or permitted by applicable law.

If you have any questions regarding this notice or our health information privacy policies, please contact Couch & Hammond Dentistry Partnership

970 Camerado Drive Suite 100
Cameron Park, CA 95682
(530)677-0723 * FX (530)677-0366

260 Palladio Parkway #1001
Folsom, CA 95630
(916)805-5077 * FX (916)293-8215

www.couchandhammonddentistry.com

Signature:

Date: