Richard Bowen, DDS www.bowenlegacydental.com
Taryn Gehlert, DDS Tel:614-459-2300
General, Cosmetic & Implant Dentistry 770 Jasonway Ave
  Columbus, OH 43214
Patient Information
    • Date:

    Our passion is to provide you with a totally different experience. Giving you the results you are seeking with better commun ication and treatment options. We are creators of new lifestyles through smiles.

    • Dr. Mr. Mrs. Ms.
    • Name:
    • I prefer to be called:
    • Person Responsible for account:
    • Relationship:
    • Home Address:
    • City:
    • State:
    • Zip:
    • Marital Status:
    • Single Married Separated Widow(er)
    • Home Phone:
    • Work Phone:
    • Cell:
    • Email:
    • Where do you prefer to receive calls?
    • Birth date:
    • Soc.Sec#
    • Drivers Lic.#
    • What is your occupation?:
    • Employer
    • Name of Spouse or Parent if Minor
    • If Patient is a minor, Mother & Father's names & birthdates:
    • How did you hear about our office?
    • Internet search Online Reviews Print Media Personal Referral Social Media
    • Personal referral: If so, whom may we thank?


    EMERGENCY INFORMATION
    • In case of emergency who should we contact?
    • Name:
    • Phone:
    • Relation:

    INSURANCE INFORMATION

    • Do you have dental insurance?:
    • Yes No
    • If yes, which carrier?
    • Policy holder name:
    • DOB:
    • SS#:
    • Employer:
    • Insurance Company:
    • Address:
    • Phone:
    • Group#:
    • Policy#:
    • Do you have secondary insurance?
    • Initials:
    • Date:
Richard Bowen, DDS www.bowenlegacydental.com
Taryn Gehlert, DDS Tel:614-459-2300
General, Cosmetic & Implant Dentistry 770 Jasonway Ave
  Columbus, OH 43214

HEALTH HISTORY
    • Name of personal physician:
    • Phone#
    • Date of last physical:
    • How do you assess your current health?
    • Excellent Good Fair Poor
    • Are you currently under the care of a physician?
    • YES NO
    • Please list any specialists you see and their specialty
    • Please mark any that apply:
      • Anxiety
        AIDS/HIV
        Arthritis, Rheumatism
        Artificial Heart Valves
        Artificial Joints
        Asthma
        Bleeding Abnormally
        Blood Disease
        Cancer
        Chemotherapy
        Circulatory Problems
        Cortisone Treatments
        Cough, Persistent
      • Diabetes Type
      • Depression
        Epilepsy
        Fainting or Dizziness
        Glaucoma
      • Heart Lesions
        Heart Murmur
        Heart Problems
      • Hepatitis Type
      • High Blood Pressure
        Kidney Disease
        Liver Disease
        Mitral Valve Prolapse
        Nervous Problems
        Pacemaker
        Psychiatric Care
        Radiation Treatment
        Rheumatic Fever
        Scarlet Fever
        Sinus Trouble
        Sleep Apnea
        Stroke
        Swollen Feet or Ankles
    • Swollen Neck Glands
      Thyroid Problems
      Tonsillitis
      Tuberculosis
      Tumor/Growth in head
      Ulcer
      Headaches
      Jaw Pain
      Jaw Popping
      Limited Opening
      Congested Ears
      Posture Problems
      Clenching
      Grinding
      Facial Pain
      Neck Ache
      Bell's Palsy
    • Please list any allergies:
    • Have you taken or are you currently taking medications for osteoporosis known as bisphosphonates? (For example Fosamax, Acton el or Boniva) :
    • YES NO
    • If yes, medication name:
    • Dates
    • Do you smoke or use chewing tobacco?
    • How much?
    • For how long?
    • In the last 5 years have you seen a
    • Chiropractor Massage Therapist Neurologist ENT
    • Are you currently taking prescription medications? If yes, please list name dosage and purpose
    • Initials:
    • Date:
Richard Bowen, DDS www.bowenlegacydental.com
Taryn Gehlert, DDS Tel:614-459-2300
General, Cosmetic & Implant Dentistry 770 Jasonway Ave
  Columbus, OH 43214

DENTAL HISTORY
    • If you could wave a wand and change anything you could about the appearance of your smile, what would you want different?
    • What was the date of your last dental visit?
    • Previous Dentist Name
    • City, State
    • Phone
    • Have you ever had a less than positive dental experience?
    • If so, please explain
    • Have you seen an Orthodontist, had your bite adjusted, or been treated for TMJ?
    • What is the most important thing to you about your future smile and dental health?
    • What is the most important thing to you about your visit today?
    • If you could whiten your teeth for a cost anyone could afford, would you do it?
    • Have you professionally whitened before?
    • YES NO
    • Please check any of the following that applies to you:
    • On a scale of 1-10, with 10 being the highest rating:
    • Bad breath or bad taste in your mouth
      Bleeding, swollen or irritated gums
      Broken tooth or fillings
      Clicking, popping in jaw joint
      Grinding or clenching teeth
      Headaches, ear aches, neck pain
      Jaw joint pain
      Loose, tipped or shifting teeth
      Mouth ulcers or cold sores
      Muscle pain in the jaw, temple region, neck area
      Sensitivity
      Tooth pain or discomfort when chewing
      Trouble sleeping
      Snoring
      • How important is your dental health to you?
      • 1 2 3 4 5 6 7 8 9 10
      • Where would you rate your current dental health?
      • 1 2 3 4 5 6 7 8 9 10
      • Importance of my overall health?
      • 1 2 3 4 5 6 7 8 9 10
      • Importance of preventive care to me?
      • 1 2 3 4 5 6 7 8 9 10
      • Importance of a cosmetic smile?
      • 1 2 3 4 5 6 7 8 9 10
    • How often do you brush your teeth?
    • How often do you floss?
    • What other dental aids do you use? (Electric toothbrush, Water-Pik, toothpicks, Soft-Picks, etc)
    • Initials:
    • Date:
Richard Bowen, DDS www.bowenlegacydental.com
Taryn Gehlert, DDS Tel:614-459-2300
General, Cosmetic & Implant Dentistry 770 Jasonway Ave
  Columbus, OH 43214

CONSENT TO DENTAL PHOTOGRAPHY
    • I, authorize Bowen Legacy Dental, to take photographs, and/or videos of my face, jaws and teeth, before during and after treatment.

    • I consent to allow the photographs to be used for the follow:
    • 1) Dental Records
    • 2) Dental Research
    • 3) Dental Education including lectures, seminars, demonstrations and professional publications such as journals or books
    • 4) Marketing material, including websites and printed materials, patient education and social media posts
    • I further understand that if the photographs and/or videos are used, my full name and/or other identifying information will be kept confidential.
    • I do not expect compensation, financial or otherwise, for the use of these photographs.
    • Patient Signature:
    • Date
    •  
    • -OR-
    •  
    • I do not want my full-face shot used for any of the above purposes
    • Patient Signature:
    • Date
Richard Bowen, DDS www.bowenlegacydental.com
Taryn Gehlert, DDS Tel:614-459-2300
General, Cosmetic & Implant Dentistry 770 Jasonway Ave
  Columbus, OH 43214

FINANCIAL GUIDELINES
    • We are committed to providing you with the highest quality lifetime dental care, so that you may fully attain optimum oral health. Please understand that payment of your bill is considered part of your treatment.

    • Payment is due at the time service is provided. Our office accepts cash, personal checks, MasterCard, Visa and Discover. Outside financing is available upon request and approval.
    • Please check if you would like more information about financing options.
    • Please note: Returned checks will be subject to additional fees. In the case it becomes necessary for our office to enlist a collection service and/or legal assistance; you will be responsible for any collection and/or legal charges incurred.
    • Do you have insurance?
    • 1) As a courtesy to you we will help you process all insurance claims. Please understand that we will provide an insurance estimate to you, however it is not a guarantee that your insurance will pay exactly as estimated. Your insurance company and your plan benefit ultimately determine the amount paid. We will, of course, do all we can to make sure your estimate is as accurate as possible.

    • 2) All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer and your insurance company. Our office is not a party to that contract.

    • 3) Our practice is committed to providing the best treatment for our patients and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company's arbitrary determination of usual and customary rates.
    • 4) If payment is not received or your claim is denied, you will be responsible for paying the full amount at that time.
    • We thank you for the opportunity to serve your dental health care needs and welcome any questions you may have concerning your care or our financial policy.
    • I have read, understand and agree to the above terms and conditions.
    • Patient Signature:
    • Date
Richard Bowen, DDS www.bowenlegacydental.com
Taryn Gehlert, DDS Tel:614-459-2300
General, Cosmetic & Implant Dentistry 770 Jasonway Ave
  Columbus, OH 43214

ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES
    • I, have received a copy of this office's Notice of Privacy Practices.

    •  
    • Signature:
    • Date
    •  
    • *You may refuse to sign this acknowledgement*
    •  
    • Refusing:
    • Date
    •  
    •  
    • HIPAA Release of Information
    •  
    • I, authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to:
    •  
    • Spouse
    • Child(ren)
    • Other
    • Information is not to be released to anyone
    •  
    • This release of information will remain in effect until terminated by me in writing.
    •  
    •  
    • Messages
    • Please call:
    • My home My work My cell
    •  
    • If unable to reach me:
    • You may leave a detailed message
      Please leave me a message asking me to return your call
    •  
    • The best time to reach me is (day)
    • between (times)
    •  
    • Signature
    • Date
    •  
    • Witness
    • Date
 
Richard Bowen, DDS www.bowenlegacydental.com
Taryn Gehlert, DDS Tel:614-459-2300
General, Cosmetic & Implant Dentistry 770 Jasonway Ave
  Columbus, OH 43214

OXYGEN/OZONE THERAPY INFORMED CONSENT
    • I, , do voluntarily, knowingly, and willingly give my consent to the administration of dental oxygen/ozone treatments. I seek this treatment at my own request.

    • I understand that dental oxygen/ozone therapy involves the injection of mixture of oxygen and ozone in the form of a gas with or without local anesthetic, into the skin, mucous membranes, muscles, joints, jawbones, and teeth of the head, neck and associated structures. Dental oxygen/ozone therapy is defined as the creation of a therapeutic oxygen rich environment, which induces a multi-factorial positive biochemical and following dental relevant and useful properties: it kills bacteria, viruses, fungi and parasites. It is circulatory stimulant, a wound-cleanser, and accelerant for wound healing, a hemostatic agent, and an immune activating agent. There may be other effects that at this time are unknown.
    • I understand that I should tell the doctor or staff if. I have ever had an allergic reaction to any anesthetic, particularly dental anesthetics prior to any treatment involving injections with anesthetics.
    • There are potential side effects with all types of dental treatments. Dental oxygen/ozone therapy carries with it some risk of side effects, such as: pain and/or discomfort at the injection site, soreness and temporary bruising. There may be a red, inflamed, blister type area at the injection site. This area usually heals a 1-5-day time period. All types of medications have some risk of allergic reactions. An allergic reaction to the mixture of oxygen/ozone would be unusual and usually restricted to the injection site. The most common patient comment is that there is a warm to burning sensation at the site of the injection. Some patients any experience flu-like symptoms for 2 to 3 days following treatment.
    • Patient/Legal Guardian:
    • Date
    • Witness:
    • Date

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