Patient Health Record

*Red Fields are required


(Last)

(First)

(Middle Initial)

(Preferred Name)

(Street)
(City, State)

(Zip Code)

Do you prefer
TEXT EMAIL BOTH

Married Single

Dental Health

Yes No
If yes, when?
Yes No
Yes

Today's Dentistry

Most updated Med HX 11/17/2016

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or

Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No
Yes No

Woman: Are you . . .

Not Pregnant? Nursing? Pregnant? Taking oral contraceptive?

Are you alergic to any of the following?

Acrylic Clindamycian Ibuprofen Local Anesthetics Penicillin Cephalosporin
Aspirin Codeine Latex Metal Sulfa Drugs
allergy
Yes No

Do you have, or have you had, any of the following?

AIDS/HIV Positive Bruise Easily Frequent Cough High Cholesterol On Autism Spectrum Sinus Trouble
Acid Reflux/GERD Celiac Disease Frequent Headaches Hives or Rash Organ Donation Spina Bifida
Alzheimer's Disease Chemotherapy Genital Herpes/VD Human Papilloma Virus Osteoporosis Stomach/Intestinal Disease
Anaphlaxis Chest Pains Glaucoma Hypoglycemia Pain in Joints Stroke
Anemia Cold Sores/Fever Blisters Hay Fever Irregular HeartBeat Parathyroid Disease Swelling of Limbs
Angina Congenital Health Disorder Heart Attack/Failure Irritable Bowel Psychiatric Care Syncope
Anxiety Crohn's Disease Heart Murmur Kidney Problems Radiation Treatments Thyroid Disease
Arthritis/Gout Diabetes Type I Heart Pacemaker Leukemia Renal Dialysis Tonsillitis
Artificial Heart Valve Diabetes Type II Heart Trouble/Disease Liver Disease Rheumatic Arthritis Tuberculosis
Artificial Joint Drug Addiction Hemophilia Low Blood Pressure Rheumatic Fever Tumors or Growth
Asthma Easily Winded Hepatitis A Lung Disease Scarlet Fever Ulcers
Blood Disease Emphysema/COPD Hepatitis B or C Mitral Vavle Prolapse Shingles Vertigo
Blood Transfusion Epilepsy/Seizures Herpes Multiple Sclerosis Sickle Cell Disease Yellow Jaundice
Breathing Problems Excessive Bleeding High Blood Pressure
Yes No

Comments:

To the best my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to

Signature of Patient, Parent or Guardian:

TODAY'S DENTISTRY, PC

Michael P. O'Neil, DDS
12953 Publishers Drive, Suite 100
Fishers, IN 46038

PATIENT CONSENT FOR USE AND DISCLOSURE
OF PROTECTED HEALTH INFORMATION

With my consent, Today's Dentistry, PC may use and disclose Protected Health Information (PHI) about me to carry out Treatment, Payment, and Healthcare Operations (TPO). Please refer to Today's Dentistry. PC Notice of Privacy Practices for a more complete description of such uses and disclosures.

I have the right to review the Notice of Privacy Practices prior to signing this consent. Today's Dentistry, PC reserves the right to revise its Notice of Privacy Practices at any time. A revised Notice of Privacy Practices may be obtained by forwarding a written request to Today"s Dentistry, PC, Privacy Officer at 12953 Publishers Drive. Suite 100, Fishers, IN, 46038. With my consent, Today's Dentistry. PC may call my home. cell phone or other designated locations, text my cell phone. email and leave a message on voice mail or in person in reference to any items that assist the practice in carrying out (TPO) Treatment, Payment, and Healthcare Operations such as appointment reminders, insurance items, and any call pertaining to my clinical care.

With my consent, Today's Dentistry, PC may mail to my home, e-mail or fax to a specified number or other designated locations any items that assist the practice in carrying out Treatment, Payment, and Healthcare such as appointments. reminder cards. pre-treatment information. dental claims and patient statements.

Today's Dentistry will disclose to me any breach of unsecured protected health information. A separate authorization is required from me for Today's Dentistry to use or disclose any of my protected health information (PHI) for marketing purposes.

By signing this form. I am consenting to Today's Dentistry, PC use and disclosure of my Protected Healthcare information to carry out Treatment, Payment, and Healthcare Operations. I also acknowledge availability to review and/or receiving a copy of Today's Dentistry, PC Notice of Privacy Practices.

I may revoke my consent in writing except to the extent that the practice has already made disclosure in reliance upon my prior consent. lf l do not sign this consent, Today': Dentistry, PC may decline to provide treatment to me.

Today's Dentistry, PC has my permission to discuss my Protected Health Information to carry out Treatment, Payment, and Health Operations with .
Parent name of Spouse or other designated individual

Patient's Name Date

Signature of Patient or Legal Guardian

Email Address

Printed Name of Legal Guardian or Patient Cell Phone



TODAY'S DENTISTRY, PC

Michael P. O'Neil, DDS
12953 Publishers Drive, Suite 100
Fishers, IN 46038

Written Financial Policy

Thank you for choosing Today's Dentistry. Our primary mission is to deliver the best and most comprehensive dental care available. This service is based on a friendly team and professional understanding between our office team and patient.

An important part of our mission is making the cost of optimal care as easy and manageable for our patients as possible by offering several payment options. Payment Options

You can choose from:

  • Cash. Check. Visa. MasterCard, American Express or Discover Card

We offer an 8% courtesy accounting adjustment to patients who pre-pay for their treatment in full with cash or check or 5% courtesy adjustment for pre-payment in full with credit card.3

  • Convenient Monthly Payment Plans' from CareCredlt
    • Allows you to pay over time
    • No annual fees or pre-payment penalties

Please note:

Today's Dentistry requires payment prlor to the completion of your treatment. If you choose to discontinue care before treatment ls complete, your refund will be determined upon review of your case.

For plans requiring multiple appointments. alternative payment arrangements may be provided. For larger. more comprehensive sedation treatment plans, a $310 deposit is required to secure each sedation treatment appointment.

For patients with dental Insurance. we are contracted with three dental insurance carriers. Delta Dental _ Premiere. HRl_ Inc (Health Resources). and Aetna. We are happy to work with your carrier to maximize your benefits and directly bill them for reimbursement for your treatment.2

Failure to pay in one of the above agreed upon manners (delinquent accounts) may be turned over to the collection agency. ln this case. the patient is responsible for all costs associated with the collection procedure: including attorney fees where applicable. Today's Dentistry charges $15.00 for returned checks.

lf you have any questions. please do not hesitate to ask. We are here to help you get the dentistry you want or need.




Patient Parent or Guardian Signature

Date


Patient Name(Please Print)

1Subject to credit approval
2However. if we do not receive payment from your insurance carrier within 90 days. you will be responsible for payment of your treatment fees and collection of your benefits directly from your insurance carrier.
3'Discounts do NOT apply to patient with an active Quality Dental Plan in affect.



Please enter code above in the field below.