Online Registration - Marquez Integrative Dental

Patient Name

First

Middle

Last

Address

Address Line 1

Address Line 2

City

State

Zip Code

Social Security Number:

Date / Time

Age

Spouse's Full Name

First

Middle

Last

Spouse's Employer

Occupation

Emergency Contact

Phone

Relationship

If patient is a minor, please give the parent or guardian's full name:

Who is responsible for this account

How did you hear about out office?

Insurance Information

Do you have Dental Insurance?

Yes
No (ask about our In-House Membership)
Self Pay

Assignment and Release

I certify that I (or my dependent) have insurance coverage as indicated and assign directly to this office all insurance benefits otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all insurance submissions.

Responsible Party Signature

Clear Signature

Date

Medical History Profile

Name and Number of Physician/Physicians

Name

Phone Number

Have you been under the care of a medical doctor/ doctors anytime during the past two years?

Yes
No

Last visit to Medical Doctor was when:

Have you been hospitalized recently?

Yes
No

List medications taking if same

Any other disease, condition or problem not listed?

List any allergies to any medications

For women: Are you pregnant?

Yes
No

Patient Signature

Clear Signature

Date

Patient History

What concerns you today the most about your teeth?

When was your last dental visit?

With whom?

What was done then?

When was your last complete dental exam with x-rays?

Cleaning?

Have you ever had problem associated with previous dental treatment?

Yes
No

Have you ever been dissatisfied with dental treatment in the past?

Yes
No

Have you noticed loosening or separation of your teeth?

Yes
No

Have you ever had gum problems?

Yes
No

Do you have problems with bad breath or bad taste?

Yes
No

Do you experience any sensitivity when chewing?

Yes
No

Do you experience any discomfort in any part of your mouth when brushing?

Yes
No

Do you feel any discomfort on any of your teeth when they contact

hot foods or liquids like soup, coffee, tea, etc?

Yes
No

cold foods or liquids, i.e. ice, cold fruit, etc.?

Yes
No

sweets i.e. candy, fruit, sweet desserts, etc.?

Yes
No

sours, i.e. lemons, limes, grapefruit, etc.?

Yes
No

Are you aware of any swelling or lump in your mouth?

Yes
No

Do you have difficulty with chewing on any part of your mouth?

Yes
No

Do your jaws tend to tire easily?

Yes
No

Do you get headaches around the temples or back of the neck?

Yes
No

Has your jaw ever locked in an opened or closed position?

Yes
No

Have you ever had or have you ever considered wearing braces?

Yes
No

Do you or have you ever worn removable partial dentures?

Yes
No

Do you have any crown or bridge work in your mouth?

Yes
No

Do you smoke?

Yes
No

Do you snack between meals frequently?

Yes
No

Do you drink sodas or any sweetened drinks often?

Yes
No

List all the different drinks that you drink including diet drinks

Are you a Gum chewer?

Yes
No

Are you a candy eater?

Yes
No

Are you a lemon eater?

Yes
No

Do you feel that you are constantly developing new dental problems?

Yes
No

Are you comfortable with the appearance of your teeth?

Yes
No

Would you like your teeth to be whiter?

Yes
No

Add anything you feel may be important regarding your dental treatment now or in the past

Based on services that we can provide you with, what do you want ideally for your teeth and oral health?

Signature

Clear Signature

Date

Fatigue Severity Scale (FSS)

Please circle the number between 1 and 7 which you feel best fits the following statements. This refers to your usual way of life. 1 indicates "strongly disagree" and 7 indicates "strongly agree."

During the past week, I have found that

Total Score

Mean Score

FSS mean score= total score for 9 items divided by 9

Read the next section closely. Ask yourself: "How energetic do I feel On a Scale of 1 to 10?"

Selected Value: 0

0 being worst and 10 being normal.

Medication Notice

Many of our Patients have begun to take the prescribed medications that fall under the category of bisphosphonates. Some of the more common names are Fosamax®, Aredia®, Boniva®, Actonel®, Skelid®, Didronel® or Zometa®. There are IV forms of the medication such as Aredia®, Zometa®, and Bonefos®. There are other names for these medications as well. These medications are commonly prescribed to control osteoporosis, maybe Padget's disease and to treat certain types of cancers in a high dose IV form. Our concern with this medication is that it has recently been linked to a serious bone disease called osteonecrosis of the Jaw (ONJ).

It is important that we know if you are taking or have taken any of these medications. If you are unsure, please let us know.

Check one and sign

I am not nor have I ever taken any medications for Osteoporosis nor have I received the IV form of the medication as part of Cancer treatment.
Yes I acknowledge that I am taking or have taken the above listed medication.

Patients With Insurance

Insurance is beneficial to many of our patients but their coverage is not always predictable. Our practice is Patient Need Driven (i.e. we want to do what is best for the patient) not Insurance Driven (i.e. what is best for the insurance company). Many Insurance plans called HMO's and DMO's work with selected doctors try to implement their fees and their recommended treatment. This treatment is insurance driven and for this reason Dr. Marquez has refused to participate in any of these plans. You should always consider what your needs and your desires are for your dental health now and in the future.

We will do our best to optimize your insurance coverage

We will help you file your claim
We will provide the insurance company with pertinent claim information
Provide X-rays if requested

It is then up to the insurance company to pay the coverage due; however every insurance company is different and some are resistant to making payments as required. They are required by law to clear the claim within 30 days. You are the insurance customer and it is then up to you to contact the insurance company and complain if there is a problem.

Please realize that you are responsible for your account balance. In the event that the insurance company does not pay for your services within 30 days after treatment is completed, we will ask that you pay us for the services rendered while you resolve the issue with your insurance company.

lf you have any questions or concerns about you insurance coverage, please feel free to discuss them with us.

Patient Signature

Clear Signature

Date

Office Payment Policy

Thank you for choosing Dr. Alfred Marquez to address your dental needs. Our primary mission is to deliver the best and most comprehensive dental care available. An important part of the mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options.

Please note: We require payment prior to the completion of your treatment

You can choose from:

Cash, Check or Credit Card (Visa, MasterCard, Discover or American Express)
We offer courtesy accounting discounts in certain instances

If you have questions about your treatment plan or the choice of payment options, please do not hesitate to ask. We are here to help you get the dentistry you want and need.

Patient Name

Patient, Parent or Guardian Signature

Clear Signature

Date

Statement of Privacy Practices

Dr. Marquez and his team are dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The commitment of each employee to ensure that your health information is never compromised is a principle concept of our practice. We may, from time to time, amend our privacy policies and practices. A current copy will always be available for your review at our office.

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 Texas. This includes relating to your treatment, payment, and our dental 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 office and electronic systems are secure from unauthorized access and our employees are trained to make certain that the confidentiality of your record 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

We will only request personal information needed to provide our standard of quality dental care, implement payment activities, conduct normal dental practice operations, and comply with the law. This may include your name, address, telephone numbers, 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 ifit 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

As stated above, we may disclose information as 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.

PATIENT RIGHTS

You have the 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 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 US Department of Health and Human Services.

Please let us know if you have any questions concerning your privacy rights and the protection of your personal health information.

Patient/Guardian Signature

Clear Signature

Acknowledgement of Receipt of Statement of Privacy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the office of Dr. Alfred Marquez. 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 dental care operations, including communications with referring dentists. The Statement of Privacy Practices also describes my rights and the responsibilities and the duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the office.

Dr. Marquez 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.

Additional Disclosure Authorization

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

Patient Name

Signature of Patient or Personal Representative

Clear Signature

(must be signed by legal parent/adult guardian, 18 yrs or older)

Description of Personal Representative's Authority

Date

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Insurance Information

Assignment and Release

Medical History Profile

Name and Number of Physician/Physicians

Indicate which of the following you have had or have at the present time:

Patient History

Fatigue Severity Scale (FSS)

Medication Notice

Patients With Insurance

Office Payment Policy

Statement of Privacy Practices

Acknowledgement of Receipt of Statement of Privacy Practices

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