WELCOME TO HUDSON DENTAL!
Will you please help us by providing the following information?
CLIENT INFORMATION
Last Name
First Name
Address
City
State
Zip
Home Phone
Work Phone
Cell Phone
Email
SS#
Date of Birth
Sex
M F
Marital Status
SMS Text: Yes
How did you find us?    Name of referring person
Employer
Address
City
State
Zip
Emergency Contact Name
Phone
Relationship to client
Occupation

PRIMARY INSURANCE
Company Name
Address
City
State:
Zip:
Subscriber Name
Relation to patient
SS#/ID#
D.O.B
Employed by
Business address
City
State:
Zip:
Group or Policy#

SECONDARY INSURANCE
Company Name
Address
City
State:
Zip:
Subscriber Name
Relation to patient
SS#/ID#
D.O.B
Employed by
Business address
City
State:
Zip:
Group or Policy#
I hereby authorize the release of any information to my insurance company or companies, including records of examinations, diagnosis and/or treatment. This release is solely for the purpose of facilitating the billing and reimbursement directly to Dr. Daniel Suh, of insurance benefits under which I am entitled. I hereby agree that I am financially responsible for all treatment rendered, and understands that complete payment will be made after each treatment, unless other financial arrangements have been previously arranged.
Date
Patient’s Signature _________________________

Reason for the visit
Former dentist             Date of the last visit?
Is keeping your teeth important to you? Yes No
if yes,
On a scale of 1-10, 10 being the best, where would you rate you smile?
On a scale of 1-10, 10 being the best, where would you rate your oral health?
Have you experienced any of the following problems?
 
Bleeding gums
Yes No
Sensitivity to hot/cold
Yes No
Bad breath or sour taste in mouth
Yes No
Snoring
Yes No
Burning sensation in mouth
Yes No
Food catching between teeth
Yes No
Sores or growths in your mouth
Yes No
Grinding of teeth
Yes No
Is it hard for you to open wide ?
Yes No
Pain/soreness around ears, eyes, face
Yes No
Clicking or popping jaw?
Yes No
Stiff neck muscles
Yes No
Had you parents suffered from gum disease
Yes No
Did you ever wear braces or invisalign?
Yes No
Ever been injured in your mouth or head
Yes No
Oral surgery or any kind?
Yes No
Does having dental treatment make you afraid or nervous? Yes No
If yes, what specific things bother you?

If you could change anything about your smile which of the following would you want?
 
Whiter
Yes No
Close space or spaces
Yes No
Replace chipped teeth
Yes No
Replace missing teeth
Yes No
Replace old crowns
Yes No
Remove silver fillings
Yes No
Remove stains/spots
Yes No
Excess showing of teeth
Yes No
Replace plastic fillings
Yes No
Straighter
Yes No
Less gum showing
Yes No
Reshape/resize my teeth
Yes No

Where do you see yourself and your overall health and/or your smile in the next five to ten years?
What is important for making dental decisions
Convenience
Appearance
Relationship w/dental team
Finances
Time
Quality of care
Insurance coverage
Health
Detailed treatment explanations
Fear or anxiety
Comfort
Technology

Medical History
Are you in good health?
Yes No
Has there been a change in your health within the last year?
Yes No
If yes explain
Have you been hospitalized or had a serious illness in the last 5 years?
Yes No
If yes explain
Are you being treated by a physician now?
Yes No
If yes explain
Name of your physician Date of last medical exam:
Office Phone#

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 phentemine), pondimin(fenfluramine)and Redux(dexfenfluamine). Yes No

(Women) Are you pregnant?
Nursing?
Taking birth control pills?
Yes No
Yes No
Yes No
Please check the following questions

Anemia
Cortisone Treatments
Hepatitis
Scarlet Fever
Arthritis, Rheumatism
Cough, Persistent
High Blood Pressure
Shortness of Breath
Artificial Heart Valves
Cough up Blood
HIV/AIDS
Skin Rash
Artificial Joints
Diabates
Jaw Pain
Stroke
Asthma
Epilepsy
Kidney Disease
Swelling of feet of Ankles
Back Problems
Fainting
Liver Disease
Thyroid Problems
Blood Disease
Glaucoma
Mitral Valve Prolapse
Tobacco Habit
Cancer
Headaches
Pacemaker
Tonsillitis
Chemical Dependency
Heart Murmur
Radiation Treatment
Tuberculosis
Chemotherapy
Heart Problems
Respiratory Disease
Ulcer
Circulatory Problems
Hemophilia
Rheumatic Fever
Venereal Disease


MEDICATIONS
List medications you are currently taking;
ALLERGIES
please list all allergies:

DO YOU TAKE OR HAVE YOU TAKEN
Recreational drugs
Yes No
Alcohol
Yes No Amount
Tobacco in any form
Yes No Amount
Phen Phen diet pills or any other diet pills
Yes No

TO ALL PATIENTS:
Do you have or have you had any other diseases or medical problems NOT listed on this form?
Yes No   If so, please explain:
Have you ever been told by a physician or dentist that you need to pre-medicate prior to any dental treatment?
Yes No



Notice of Privacy Practices


This notice describes how health information about you may be used and disclosed, and how you can get access to this information. Please review carefully. If you have any questions about this Notice, please contact out Privacy Officer.

This Notice of Privacy Practices describes how we may used and disclosed your protected health information to carry out treatment, payment or health care operations and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. We are required by Federal Law to give you this Notice and to maintain the privacy of your health information. We must also abide by the terms of this Notice while it is in effect. We reserve the right to change our privacy practices and terms of this Notice at any time. Before we make significant changes in our privacy practices, we will change this Notice and make the new Notice available upon request.

Uses and Disclosures of Protected Health Information
You will be asked to sign an Acknowledgement of Receipt of Notice of Privacy Practices. Once you have received our Notice of Privacy Practices, disclosure of your protected health information will be used for treatment, payment and health care operations. Your protected health information may be used and disclosed by our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you. Your protected health information may also be used and disclosed to pay your health care bills and to support the operation of our practice. Following are examples if the types of uses and disclosures of your protected health care information that our office is permitted to make:

Treatment- We will use and disclose your protected health care information to others dentist and physicians to provide, coordinate, or manage your health care. For example, your protected health care information may be provided to another dentist to whom you have been referred to ensure that the necessary information is available to diagnose or treat you. In addition, we may disclose your health information at times to a dental laboratory or specialist.

Payment- Your protected health information will be used to obtain payment for services we provide to you. This may include certain activities that your insurance plan may undertake before it approves or pays for the services we recommend.

Healthcare Operations- We may use or disclose your protected health information in order to support the business activities of our practice. These activities include, but are not limited to, quality assessment activities, employee review activities, licensing, credentialing activities, conducting training and conducting other business activities. For example, we may use a sign-in sheet at the front desk where you will be asked to sign your name when you arrive. We may also call you be name in the waiting room when your doctor is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

Business Associates- We will share your protected health information with third party Business Associates that perform various activities (billing or laboratory services) for the practice. Whenever an arrangement between our office and a business associate involves the use or disclosure of your protected health information, we will have a written contract that contains terms that will protect the privacy of your protected health information.

We may use or disclose your protected health information, as necessary, to provide you with information about treatment alternatives or other health-related benefits and services that may be of interest to you. We may also use and disclose your protected health information for other marketing activities. For example, your name and address may be used to send you a newsletter about our practice and the services we offer. We may also send you information about products or services that we believe may be beneficial to you. You may contact our Privacy Officer to request that these materials not be sent to you.

Uses and Disclosures of Protected Health Information Based Upon Your Written Authorization
Other uses and disclosures of your protected health information will be made only with your written authorization, unless permitted or required by law as described below. You may revoke this authorization, at any time, in writing, except to the extent that our practice has already taken an action as provided for in the authorization.

Other Permitted and Required Uses and Disclosures the May be Made with Your Consent, Authorization or Opportunity to Object
We may use and disclose your protected health information in the following instances. You have the opportunity to agree or object to the use or disclosure of all or part of your protected health information. If you are not present or able to agree or object to the use or disclosure of the protected health information, then we may, using professional judgment, determine whether the disclosure is in your best interest. In this case, only the protected health information that is relevant to your health care will be disclosed.