Patient Intake Form

“Dr. Ford has been the best dentist! He cares a lot! I just made the transition to see him and I sure am glad that I did.”
– Kyler E.

New Patients Call
(425) 336-3566

Book Appointment

Existing Patients
(425) 277-0125

1 Patient Information
2 Insurance Information
3 Dental/Medical History
4 Medical History (Continued)
5 Office Policy
HIPAA

Phone

First Name *

Middle

Last Name *

Preffered Name

Date of Birth *

Gender *

Male

Female

Relationship Status *

Married/Domestic Partner

Single

Address *

Street Address

Address Line 2

City

State

Zip

Cell *

Home

Work

Place of Employment

Social Security Number

Email *

Physician's Name

Phone

In case of Emergency, Whom may we contact?

Name *

Phone 1 *

Phone 2

Relationship To Patient *

Insurance:

Do You Have Dental Insurance? *

Yes

Dental History

Do you have a specific dental problem or concern? *

Yes

Have you had an upsetting experience in a dental office or do you feel nervous about having dental treatment? *

Yes

Do you have TMJ problems? (Bruxing, Grinding Teeth/Popping, Clicking or Discomfort Around Jaw Joint) *

Yes

Name of Previous Dentist where we may obtain prior x-rays, etc.

When was your last dental exam?

Medical History

Medical Doctor's Name

Prefix

First Name

Last Name

Phone No.

Date of Last Physical Exam

Has your physician ever indicated that you should be pre-medicated with antibiotics prior to dental treatment? *

Yes

Are you under a doctor's care now? *

Yes

Have you been hospitalized or had surgery in the last 5 years? *

Yes

Have you had surgery or x-ray treatment for tumor, growth, or other condition of your mouth or lips? *

Yes

Have you had abnormal bleeding associated with previous extractions, surgery, or trauma? *

Yes

Do you or have you used tobacco products? *

Yes

Are you currently pregnant? *

Yes

If recently given birth, are you breastfeeding? *

Yes

Are you taking any prescription or over-the-counter medications? *

Yes

Please check any condition(s) that you have now, or have had in the past:

Cardiovascular Disease: (heart attack, coronary insufficiency, coronary occlusion, high/low blood pressure, arterioclerosis, stroke, pacemaker)

Heart Problems: prosthetic valve, endocarditis, congenital heart disease, transplant w/ valvulopathy

Rheumatic fever, mitral valve prolapse or heart murmur

Seizures, fainting spells or epilepsy

Blood disorder, anemia or slow clotting

Hyper- or hypothyroidism

Liver: Jaundice, Hepatitis A/B/C, Cirrhos

condtions_continued

Kidney: Renal failure, Shunt, Dialysis

Tuberculosis

Glaucoma

Chemotherapy or radiation

Cold sores or herpes virus

Positive HIV, AIDS, or AIDS related complex

Frequent allergies, hives or rash

Do you have diabetes? *

Yes

Have you ever been diagnosed with cancer? *

Yes

Have you ever had a blood transfusion? *

Yes

Do you have any artificial prosthesis/implants? (Joints, hip screws, etc.) *

Yes

Is there any condition, not listed above, that we know about? *

Yes

Please check if you are taking any of the following medications:

Antibiotics or sulfa drugs

Medicine for high blood pressure

Aspirin

Digitalis or drugs for heart trouble

Anticoagulants (blood thinners)

condtions_continued

Bisphosphonates (Boniva, Actonel, Fosamax, Skelid, or Didronel)

Antihistamines

Insulin (for diabetes)

Nitroglycerin

Are you currently taking any anti-depressants? *

Yes

Are you taking any other medication(s) not listed above? *

Yes

Please check if you are allergic or have reacted adversely to any of the following medications:

Local anesthetics

Sulfa drugs

Aspirin, tylenol, ibuprofen

Barbiturates, benzodiazapines, sleeping pills

allergies_cont

Penicillin or other antibiotics

Latex

Codeine or other narcotics (e.g. Tylenol 3, Vicodin, Percocet)

Are you allergic or have adverse reactions to any other medications not listed above? *

Yes

The information provided on this medical history form is correct, to the best of my knowledge *

Appointment Cancellation Policy

When you schedule an appointment in our office we reserve that time specifically for you. If you need to cancel or reschedule your appointment we require 48 hours advance notice so that we can schedule another patient waiting for treatment. If you miss your appointment or do not give 48-hour notice, there may be a $150/hr charge applied to your account.

Initial

Office Financial Policy

Insurance If you have dental insurance, we will make a good faith estimate of the amount your insurance carrier may pay based on the information provided to us. As the insured, it is your responsibility to determine the coverage by your insurance for any dental services provided in our office. As a courtesy, we will file all dental claims on your behalf as well as provide any information required by your insurance carrier to ensure it is processed in a timely manner. If your insurer denies coverage, or if we otherwise do not receive a payment within 60 days from filing your claim, the amount will then become due and payable by you. Remember that your coverage is a contract between you and your insurer and/or your employer and your insurer. All questions regarding your insurance benefits must be addressed to your insurance carrier.
Payment The amount estimated to be your portion of treatment is due at the time dental treatment is provided. We accept payment in the forms of Cash/Check, Visa, Mastercard, Discover, Debit cards (that bear Visa or MasterCard logos), and Care Credit. Patient Responsibility, Assignment, and Release I acknowledge my responsibility for the total payment of all services performed in this office in accordance with their regular fees and terms. I understand my responsibility is not modified by whether any third party (insurance) pays for all, part, or none of the charges. I understand that any estimated portion, not covered by insurance is due at the time of service for all services rendered. I understand that my account becomes delinquent if not paid within sixty (60) days after billing and that at that time a finance charge of 1.0% of the unpaid balance will be charged every month until the balance is paid in full (RCW 19.52.020). I authorize payment to be made directly to the dentist by my insurance company and I accept financial responsibility for all services not covered by my insurance. I authorize the release of any medical/dental care information requested by my insurance carrier and authorize my insurance company to pay insurance benefits directly to the dentist for all dental services rendered. We are here to assist you in any way possible. Please make your questions and concerns known to our team. Our goal is to ensure that you have an exceptional experience!

I have read and understand the office financial and appointment cancellation policies *

Name of Patient:

First *

Last *

Name of Legal Guardian:

First

Last

Statement of Privacy Practices

Our office is dedicated to protecting the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that their health information is never compromised is a principal concept of our practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes that might affect your rights.

Protecting Your Personal Healthcare Information

We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and Accountability Act and the state of Washington. This includes issues relating to your treatment, payment, and our health care operations. Your personal health information will never be otherwise given to anyone – even family members – without your written consent. You, of course, may give written authorization for us to disclose your information to anyone you choose, for any purpose. Our offices and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your records is always protected. Our privacy policy and practices apply to all former, current, and future patients, so you can be confident that your protected health information will never be improperly disclosed or released.

Collecting Protected Health Information (PHI)

We will only request personal information needed to provide our standard of quality health care, implement payment activities, conduct normal health practice operations, and comply with the law. This may include your name, address, telephone number(s), Social Security Number, employment data, medical history, health records, etc. While most of the information will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the source, your personal information will always be protected to the full extent of the law.
Disclosure of your Protected Health Information
We may disclose information as allowed or required by law. We are obligated to provide information to law enforcement and governmental officials under certain circumstances. We will not use your information for marketing purposes without your written consent. We may use and/or disclose your health information to communicate reminders about your appointments including voicemail messages, answering machines, and postcards. You have a right to request and we will honor your written authorization to withhold disclosure to your dental insurance carrier for all services for which you have made full out-of-pocket payment. Any breach in the protection of your personal health information, including unauthorized acquisition, access, use, or disclosure, will be fully investigated, addressed, and mitigated as established by the HIPAA Privacy Rule. You have a right to and will be provided all information relating to any breach involving your personal PHI.

Your Rights as our Patient

You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request a list of instances in which we, or our business associates, have disclosed your protected information for uses other than stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of Health and Human Services. Please ask if you have any questions about your privacy rights or the protection of your health information.

601 So. Carr Road, Suite 400 * Renton, Washington 98055 * 425-271-3500

Acknowlegement of Receipt of Statement of Privacy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of David Ford, DDS. The Statement of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility. David Ford, DDS reserves the right to change the privacy practices that are described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed to me.

Initial

Additional Disclosure Authority

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below

Any member of my immediate family *

Yes No

Spouse Only *

Yes No

Other *

Yes No

New Patients Call
(425) 336-3566

Book Appointment

Existing Patients
(425) 277-0125