WHO MAY WE THANK FOR REFERRING YOU TO OUR OFFICE?
OR, DID YOU HEAR OF US FROM : INTERNET /
YELLOW PAGES / SIGN / NEWSPAPER / OTHER:
AFTER COMPLETING ALL PAGES OF THIS QUESTIONAIRE PLEASE
READ AND SIGN THE AUTHORIZATION AND RELEASE BELOW:
I certify that I have read, understood and accurately completed the personal, medical and dental question-naires to the best of my knowledge and have not knowingly omitted any information. This information has been reviewed by me, and I have had the chance to ask questions and to receive answers regarding any medi-cal and dental histories. As may be required, I consent to my physician being contacted regarding any spe-cific medical questions. I authorize Dr. Rosenblat or his employees to release any information concerning my dental treatment or my child's dental treatment to third party payers and /or other medical/dental offices. I au-thorize Dr. Rosenblat and his qualified employees to perform necessary diagnostic procedures and treatment as required to achieve the proper level of dental care including the use of local anesthesia and other medica-tion as indicated. I understand that I am financially responsible to the dentist for all costs of dental services provided, regardless of outcome, even if my insurance coverage may not be all inclusive.
The following information is required to enable us to provide you with the best possible dental care. All information is strictly private, and is protected by doctor-patient confidentiality. Dr. Rosenblat will review the questions and explain any that you do not understand. Please fill in the entire form. 1. Are you being treated for any medical condition at the present or have you been treated within the past year? If so, why?
2. When was your last medical checkup? 3. Has there been any change in you general health in the past year? If yes, please explain.
4. Are you taking any medications, non prescription drugs or herbal supplements of any kind? If yes please list them al .
5. Do you have any al ergies? If you answer yes, please list using the categories below:
6. Have you ever had a peculiar or adverse reaction to any medicines or injections? If yes, please explain.
7. Have you ever been hospitalized for any il ness or operations? If yes, please explain.
8. Do you smoke or chew tobacco products? YES NO
9. For women, are you breastfeeding or pregnant?
10. Do you have or have you ever had any of the fol owing? Please check.
11. Are there any conditions or diseases not listed above that you have had? If so, what?
Are you nervous during dental treatment? YES NO
What is the reason for today’s visit? Do you love your smile? Is there anything you would like to change? Why did you leave your last dentist? Do you have any missing teeth you would like to replace? YES NO
Root canal Teeth removed Gum surgery Implants Complications after extractions Problems with local anesthetics
Source: http://www.oakdaledental.ca/oakdalehealthformforweb.pdf
The Honorable John Boehner Speaker of the House of Representatives The Honorable Eric Cantor Majority Leader, House of Representatives The Honorable Nancy Pelosi Minority Leader, House of Representatives February 22, 2011 Dear Speaker Boehner, Majority Leader Cantor, and Minority Leader Pelosi: It is shocking to imagine that in the next major global humanitarian crisis – the next Haiti, Tsunami,
GUIDELINES FOR ELIGIBLE REIMBURSEMENTS GENERAL PLEASE COPY ALL ENCLOSURES FOR YOUR PERSONAL REFERENCE AND INCOME TAX RECORDS If you have not submitted the medical/dental expense to your insurance plan(s), please do so prior to submission on this Flexible Spending Account Reimbursement Request Form. If you apply for reimbursement of an expense that the IRS later determines to be inel