Florida Prosthodontics – Medical History If you are interested in external financing, please check Care Credit or Lending Club. Patients Name Patients Date of Birth Patients Address Patients City Patients State Patients Zip Code Patients Home Phone # Patients Cell Phone # Patients Other Phone # Patients Email Address Physicians(s) Name Physicians(s) Address Physicians(s) Phone Number Preferred Pharmacy Pharmacy Address Pharmacy Phone Number Dental Insurance: (Please bring a copy of Insurance card to your appointment). Insurance Company Policy Holder's Name Policy Holder's Date of Birth Member ID # Group # Mailing Claims Address Dental Claims Phone Number Upload Driver's license (front, back) Upload Insurance card (front, back) 1. Have you been a patient in the hospital or under the care of a medical doctor during the past two years?YesNo 2. Are you now taking any medications or drugs?(If yes, please bring a copy to your appointment)YesNo 3. Are you now taking any blood thinner medications; (i.e. Aspirin, Eliquis, Pradaxa, Xarelto, Plavix Coumadin, etc.)?YesNo 4. Are you now taking herbal supplements, vitamins, or over the counter medications?YesNo Please specify: 5. Are you now, or have you ever taken any medications in the Bisphosphonate family;(Medications used to treat osteoporosis and some cancers) i.e. Actonel, Aredia, Boniva, Fosamax, Reclast, Prolia, Xgeva, Zometa, etcYesNo Please specify: 6. Are you under the care of a pain management doctor? YesNo If so, list name 7. Are you allergic to (i.e. itching, rash, swelling of hands, feet, or eyes) or made sick by Penicillin, Aspirin, Codeine, LATEX or any drug or medication?YesNo If so, what? 8. Do you drink alcoholic beverages? YesNo How many, how often? 9. Do you or have you within the past year participated in recreational drugs? YesNo Please specify: 10. Are you a Smoker or Chew Tobacco? YesNo Please specify: 11. Are you interested in Dental Implants? YesNo 12. Have you ever had any excessive bleeding requiring special treatment? YesNo 13. When you walk upstairs or take a walk, do you ever have to stop because of pain in your chest, or shortness of breath, or because you are very tired? YesNo 14. Do your ankles swell during the day? YesNo 15. Have you lost or gained more than 10 pounds in the past year? YesNo 16. Do you ever wake up from sleep short of breath? YesNo 17. Has your medical doctor ever said you have cancer or a tumor?YesNo Please specify: 18. Do you have any disease, condition, or problem not listed?YesNo Please specify: 19. Are you currently pregnant? YesNo 20. Does your Medical Doctor require you to take any Premedication (Antibiotic) prior to any Dental Visits? YesNo hip replacement knee replacement heart replacement other Please indicate if you have had in the past or present Y (yes) or have not had N (no) to any of the following: Adrenal DiseaseYN Allergies or HivesYN AnemiaYN Angina Pectoris (Chest Pain)YN ArthritisYN Artificial Heart ValveYN Artificial JointYN AsthmaYN Blood TransfusionYN Bruise EasilyYN Chemotherapy (Cancer/ Leukemia)YN Chronic BronchitisYN Cortisone MedicineYN DiabetesYN Drug AddictionYN EmphysemaYN Epilepsy or SeizuresYN Fainting or Dizzy SpellsYN GlaucomaYN Hay FeverYN Heart Disease or AttackYN Heart FailureYN Heart MurmurYN Heart PacemakerYN Heart SurgeryYN HemophiliaYN HepatitisYN High Blood PressureYN HIVYN Jaw Joint Pain, Clicking, PoppingYN Kidney TroubleYN Liver DiseaseYN Mitral Valve ProlapseYN NervousnessYN OsteoporosisYN Psychiatric TreatmentYN Radiation TreatmentYN Recurring Mouth SoresYN Rheumatic FeverYN Sickle Cell DiseaseYN Sinus TroubleYN Smoker/ Tobacco UseYN Stomach Ulcers/ ColitisYN StrokeYN Thyroid DiseaseYN Tuberculosis (TB)YN Vascular DiseaseYN Yellow JaundiceYN To the best of my knowledge, all of the preceding answers are true and correct. If I have change in my health or if my medications change, I will inform the doctor at the next appointment without fail. Signature of Patient, Parent or Guardian Date Email I grant Florida Prosthodontics permission to use photos/videos of my Dental case for their marketing purposes. (IE: Internet web site, brochures, testimonials, social media, etc.) Signature (Your Full Name) CONSENT: The undersigned hereby authorizes Doctor to take x-rays, study models, photographs or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize Doctor to perform any and all forms of treatment, medication and therapy, that may be indicated in connection with and further authorize and consent that Doctor chose and employ such asissance as he/she deems fit. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I further understand that a 1% finance change (18% annually) will be added to any balance over 60 days. In the event of default I (we) promise to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees as may be required to effect collection of this note. Patient Date Witness Patient or Responsible Party Relationship to Patient Please answer the math question below to prove you are a human!10-3=? Our practice understands the importance of privacy and is committed to maintaining the confidentiality of your medical/dental information. We make a record of the dental care we provide and may receive similar records from other sources. We use these records to provide or enable other health care providers to provide quality dental care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this dental practice properly. We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information.
Merritt Island