ARWynnykiwDDS Welcome!€¦ · 351 Osborne Road, Loudonville, New York 12211 518.432.3991...

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351 Osborne Road, Loudonville, New York 12211 518.432.3991 518.432.3987 [email protected] www.albanydds.com ARWynnykiwDDS When it comes to dentists, I know that you have many options. My goal is get to know you as a whole person, and plan to do so through open and honest communication. I am very grateful that you have decided to consult me regarding your dental needs. :KHQ , PHHW ZLWK QHZ SDWLHQWV P\ SULPDU\ FRQFHUQ LV WKH LGHQWLˉFDWLRQ RI \RXU SHUVRQDO GHQWDO health desires and your present condition. In that regard, it is my intention to provide you with a superior evaluation of all aspects of function and esthetics. This comprehensive evaluation will include appropriate imaging and photographs, as well as an opportunity to share with me your previous dental experiences and any of your thoughts and wishes regarding your dentistry. :K\ GR , DOZD\V FRQGXFW D FRPSUHKHQVLYH H[DP" %HFDXVH , EHOLHYH WKHUH LV QR ȢRQH VL]H ˉWV DOOȣ dentistry. This comprehensive information will provide us (you, my team, and myself) with a basis for identifying solutions which appropriately address your reasons for visiting my practice and will assist us in being most effective in working with you according to your wishes. In other words, it allows us to correctly understand your intentions and expectations while giving you a chance to increase your awareness of your current dental condition before any treatment options are presented. To serve you in properly addressing your dental needs is a privilege for me; thank you sincerely for the opportunity. I look forward to seeing you soon. Sincerely, Askold R. Wynnykiw, DDS I have included a multiple page questionnaire that will assist me in getting to know you better and in being fully prepared for your visit. It may seem long, but I ask each and every question for VSHFLˉF DQG LPSRUWDQW UHDVRQV UHODWHG WR \RXU RUDO KHDOWK While I would very much appreciate having this information prior to your visit, if you would prefer completing it in person with us, please bring it along and a team member can help you (please arrive extra early). Welcome!

Transcript of ARWynnykiwDDS Welcome!€¦ · 351 Osborne Road, Loudonville, New York 12211 518.432.3991...

Page 1: ARWynnykiwDDS Welcome!€¦ · 351 Osborne Road, Loudonville, New York 12211 518.432.3991 518.432.3987 smile@albanydds.com ARWynnykiwDDS When it comes to dentists, I know that you

351 Osborne Road, Loudonville, New York 12211

518.432.3991 518.432.3987

[email protected] www.albanydds.com

ARWynnykiwDDS

When it comes to dentists, I know that you have many options. My goal is get to know you as a whole person, and plan to do so through open and honest communication. I am very grateful that you have decided to consult me regarding your dental needs.

�:KHQ�,�PHHW�ZLWK�QHZ�SDWLHQWV��P\�SULPDU\�FRQFHUQ�LV�WKH�LGHQWLˉFDWLRQ�RI�\RXU�SHUVRQDO�GHQWDO�health desires and your present condition. In that regard, it is my intention to provide you with a superior evaluation of all aspects of function and esthetics. This comprehensive evaluation will include appropriate imaging and photographs, as well as an opportunity to share with me your previous dental experiences and any of your thoughts and wishes regarding your dentistry.

:K\�GR�,�DOZD\V�FRQGXFW�D�FRPSUHKHQVLYH�H[DP"�%HFDXVH�,�EHOLHYH�WKHUH�LV�QR�ȢRQH�VL]H�ˉWV�DOOȣ�dentistry. This comprehensive information will provide us (you, my team, and myself) with a basis for identifying solutions which appropriately address your reasons for visiting my practice and will assist us in being most effective in working with you according to your wishes. In other words, it allows us to correctly understand your intentions and expectations while giving you a chance to increase your awareness of your current dental condition before any treatment options are presented.

To serve you in properly addressing your dental needs is a privilege for me; thank you sincerely for the opportunity. I look forward to seeing you soon.

Sincerely,

Askold R. Wynnykiw, DDS

I have included a multiple page questionnaire that will assist me in getting to know you better and in being fully prepared for your visit. It may seem long, but I ask each and every question for VSHFLˉF�DQG�LPSRUWDQW�UHDVRQV�UHODWHG�WR�\RXU�RUDO�KHDOWK�

While I would very much appreciate having this information prior to your visit, if you would prefer completing it in person with us, please bring it along and a team member can help you (please arrive extra early).

Welcome!

Page 2: ARWynnykiwDDS Welcome!€¦ · 351 Osborne Road, Loudonville, New York 12211 518.432.3991 518.432.3987 smile@albanydds.com ARWynnykiwDDS When it comes to dentists, I know that you

Today’s Date

Welcome!When it comes to dentists, we know that you have many options. Our goal is to get to know you as a whole person, and plan to do so through open and honest communication.

3OHDVH�ˉOO�RXW�WKLV�IRUP�FRPSOHWHO\�VR�WKDW�ZH�FDQ�SURYLGH�\RX�with the best possible service.

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Primary Insurance:Insurance Company

Address

City State Zip

Telephone

Insured’s Name

Birthdate / / Relation

Telephone

Employer

Policy ID or SS# Group #

Secondary Insurance:Insurance Company

Address

City State Zip

Telephone

Insured’s Name

Birthdate / / Relation

Telephone

Employer

Policy ID or SS# Group #

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Name Gender

Relationship Birthdate / /

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City State Zip

Telephone - Home

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SS# - - Drivers Lic. # State

Person Responsible for Account

Yes NoDo you have a personal physician? � �

Physician’s Name

Telephone

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Emergency Contact(s):Please list individual(s) we may contact in an emergency.

Name

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Full Name LAST FIRST M.I.

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Gender Birthdate / / Age

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Address

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351 Osborne Road, Loudonville, New York 12211 518.432.3991 518.432.3987 [email protected] www.albanydds.com ARWynnykiwDDS

Page 3: ARWynnykiwDDS Welcome!€¦ · 351 Osborne Road, Loudonville, New York 12211 518.432.3991 518.432.3987 smile@albanydds.com ARWynnykiwDDS When it comes to dentists, I know that you

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Person responsible for account: Please read the following and sign and date at the bottom of this form.

1. 3D\PHQW�LV�PDGH�LQ�IXOO�RQ�WKH�GDWH�VHUYLFHV�DUH�SURYLGHG���3D\PHQW�FDQ�EH�PDGH�YLD�&DVK��&KHFN��9LVD��0DVWHU&DUG��$PHULFDQ�([SUHVV��'LVFRYHU��&DUH&UHGLW��0RQH\�2UGHU��DQG�&HUWLˉHG�&KHFN��5HWXUQHG�FKHFNV�DUH�VXEMHFW�WR�D��������VXUFKDUJH�WR�\RXU�DFFRXQW�

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3. $����FRXUWHV\�FDQ�EH�GHGXFWHG�IURP�\RXU�IHHV�IRU�VHUYLFHV�RYHU���������VKRXOG�\RX�SD\�E\�FDVK��FKHFN��PRQH\�RUGHU��RU�FHUWLˉHG�FKHFN���

4. 'HQWDO�%HQHˉWV��:H�ZLOO�JODGO\�ˉOH�D�FODLP�WR�\RXU�GHQWDO�EHQHˉWV�FDUULHU�DV�D�FRXUWHV\�WR�\RX���<RXU�FODLPV�ZLOO�EH�ˉOHG�LQ�RUGHU�WKDW�WKH�LQVXUDQFH�FDUULHU�ZLOO�UHLPEXUVH�\RX�GLUHFWO\���$OO�SD\PHQW�IRU�VHUYLFHV��UHJDUGOHVV�RI�FRYHUDJH��LV�GXH�LQ�IXOO�DW�WKH�WLPH�WUHDWPHQW�LV�UHQGHUHG���,I�\RX�KDYH�QRW�UHFHLYHG�UHLPEXUVHPHQW�IURP�\RXU�LQVXUDQFH�FDUULHU�ZLWKLQ����GD\V�RI�WKH�GDWH�RI�VHUYLFH��SOHDVH�DGYLVH�XV�DQG�ZH�ZLOO�GR�RXU�EHVW�WR�UHVHDUFK�WKH�FODLP�VWDWXV�DV�D�FRXUWHV\�WR�\RX���1RWH��1R�VHUYLFHV�DUH�SURYLGHG�LQ�WKLV�RIˉFH�XQGHU�DQ\�DVVXPSWLRQ�WKDW�DQ�LQVXUDQFH�FDUULHU�ZLOO�SURYLGH�SD\PHQW��<RXU�VLJQDWXUH�RQ�WKLV�ˉQDQFLDO�DJUHHPHQW�VHUYHV�DV�\RXU�DJUHHPHQW�WR�DOORZ�XV�WR�ˉOH�DQ�LQVXUDQFH�FODLP�RQ�\RXU�EHKDOI�

,�KDYH�UHDG�DQG�XQGHUVWDQG�WKH�ˉQDQFLDO�SROLF\�RI�$�5��:\QQ\NLZ��''6��3//&���,�XQGHUVWDQG�WKDW�DV�WKH�JXDUDQWRU�RI�WKLV�DFFRXQW��,�DP�UHVSRQVLEOH�IRU�DOO�IHHV�DSSOLHG�WR�WKH�DFFRXQW�IRU�WUHDWPHQW�SURYLGHG�DQG�SURGXFWV�SXUFKDVHG�DQG�WKDW�WKHVH�IHHV�DUH�H[SHFWHG�WR�EH�SDLG�LQ�IXOO�DW�WKH�WLPH�VHUYLFHV�DUH�UHQGHUHG���,Q�DGGLWLRQ��,�DP�DZDUH�WKDW�EDODQFHV�RYHU����GD\V�SDVW�GXH�DUH�VXEMHFW�WR�DQ�����$35�������SHU�PRQWK��ˉQDQFH�FKDUJH���A 24-hour notice is required for any changes in scheduled appointments. Appointments missed or changed with less than 24-hour notice are subject to a $50.00 fee.

Date ��1DPH�RI�5HVSRQVLEOH�3DUW\� Signature

Financial Agreement

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,�DXWKRUL]H�$�5��:\QQ\NLZ��''6��3//&�WR�XVH�FOLQLFDO�DQG�SRUWUDLW�SKRWRJUDSKV�RI�P\�IDFH��MDZV��JXPV��DQG�WHHWK��,�GR�QRW�H[SHFW�FRPSHQVDWLRQ��ˉQDQFLDO�RU�RWKHUZLVH��IRU�WKH�XVH�RI�WKHVH�SKRWRJUDSKV��,�XQGHUVWDQG�WKDW�\RX�ZLOO�QRW�XVH�P\�ODVW�QDPH�DQG�ZLOO�QRW�GLYXOJH�DQ\�SHUVRQDO�LQIRUPDWLRQ�XQOHVV�H[SUHVV�ZULWWHQ�FRQVHQW�LV�REWDLQHG��,�JLYH�\RX��IRU�PDUNHWLQJ�DQG�HGXFDWLRQDO�SXUSRVHV��SHUPLVVLRQ�WR�XVH� � P\�ˉUVW�QDPH � a pseudonym

Educational Purposes.,�XQGHUVWDQG�WKDW�WKH�SKRWRJUDSKV�WDNHQ�ZLOO�EH�XVHG�DV�D�UHFRUG�RI�P\�FDUH��DQG�PD\�EH�XVHG�IRU�HGXFDWLRQDO�SXUSRVHV�LQFOXGLQJ�EXW�QRW�OLPLWHG�WR�OHFWXUHV��GHPRQVWUDWLRQV��DQG�SXEOLFDWLRQV��GHQWDO�PDJD]LQHV��MRXUQDOV��SURIHVVLRQDO�ZHEVLWHV��HWF���

Marketing & Advertising.I understand that the photographs taken may be used in marketing materials, including, but not limited to web site publication, print marketing, and VRFLDO�PHGLD��,�XQGHUVWDQG�WKDW�ZKHQ�,�UHYHDO�P\�LGHQWLW\�DQG�RU�UHODWLRQVKLS�ZLWK�WKLV�SUDFWLFH�LQ�DQ\�SXEOLF�HOHFWURQLF�IRUXP��LQFOXGLQJ��EXW�QRW�OLPLWHG�to Facebook�RU�HOHFWURQLF�UHYLHZ�ZHEVLWHV��LW�ZLOO�EH�FRQVLGHUHG�P\�YROXQWDU\�UHOHDVH�RI�WKDW�LQIRUPDWLRQ�

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,�KHUHE\�ZDUUDQW�WKDW�,�DP�RI�IXOO�DJH�DQG�KDYH�WKH�ULJKW�WR�FRQWUDFW�LQ�P\�RZQ�QDPH��,�KDYH�UHDG�WKH�DERYH�DXWKRUL]DWLRQ��UHOHDVH��DQG�DJUHHPHQW��SULRU�WR�LWV�H[HFXWLRQ��DQG�,�DP�IXOO\�IDPLOLDU�ZLWK�WKH�FRQWHQWV�WKHUHRI��7KLV�UHOHDVH�VKDOO�EH�ELQGLQJ�XSRQ�PH�DQG�P\�KHLUV��OHJDO�UHSUHVHQWDWLYHV��DQG�assigns.

Date Name Signature

Authorization to Use Photographs, Name, or Likeness

351 Osborne Road, Loudonville, New York 12211 518.432.3991 518.432.3987 [email protected] www.albanydds.com ARWynnykiwDDS

Page 4: ARWynnykiwDDS Welcome!€¦ · 351 Osborne Road, Loudonville, New York 12211 518.432.3991 518.432.3987 smile@albanydds.com ARWynnykiwDDS When it comes to dentists, I know that you

Our Goal is to get to know you as a whole person, and plan to do so through open and honest communication. Please fill out this form completely so that we can provide you with the best possible service.

Yes No

Aspirin o oCodeine o oSedatives o oLocal anesthetic* o oPenicillin o oOther Antibiotics* o oLatex o oSulfa o oNickel / other metal* o oBarbiturates o o

Yes NoIodine o oNitrous Oxide o oMilk/Casein o oChlorine/Clorox o oAre you aware of being allergic to any othermedications or substances?* o oDo you have any food allergies?* o o*If yes to any of the above items, please list/explain:

Allergies >> Are you allergic to or have you reacted adversely to any of the following?

Do you have specific questions for the dentist? Yes o No o Why have you come to the dentist today?

What prescription or non-prescription medications are you currently taking? Include herbal remedies and recreational drugs.

Pharmacy Name, Location, & Telephone:

Please check at least one box on each line below. There are no “correct” answers!

1. My mouth is: o very comfortable. o moderately comfortable. o uncomfortable.

2. My smile: o is excellent. o is not a concern to me. o could be improved.

3. My dental health is: o excellent. ogood. ofair. opoor.

4. Choose one: o I will do whatever I must to keep my teeth. o I want to keep my teeth but only within a certain budget of time and money.

5. Choose one: o In the past, I’ve done the dentistry recommended to me. o I’ve not done dentistry recommended to me. o Never been recommended.

Yes NoAre you currently in any pain? o oAre you under a physician’s care now? o oHas your physician told you that you require antibiotics before dental treatment?

o o

Have you been hospitalized or have you had a serious illness in the last three years?

o o

Have you gained or lost 10+ pounds in the past year? o oDo you wear contact lenses? o oDo you have frequent sore throats? o oDo you get/have enlarged lymph nodes/glands? o o

Yes NoDo you have any sexually transmitted infections? o oHave you tested positive for HIV/AIDS? o oDo you have any history of cancer? o oHave you undergone radiation therapy? o oHave you undergone chemotherapy? o o

If yes to any of the above items, please list/explain:

Cardiovascular >> Past or Present

Yes NoCongestive Heart Failure o oHeart Attack o oChest Pain/Angina o oHigh Blood Pressure o oHeart Murmur o oMitral Valve Prolapse o o

Yes NoRheumatic Fever o oCongenital Heart Defect o oProsthetic Heart Valve o oArrhythmias o oPacemaker or Defibrillator o oCoronary Bypass o o

Yes NoCoronary Transplant o oAneurysm o oOther Heart Condition o o(Describe):

CONTINUE ON REVERSE >>

Today’s Date

Patient Medical & Dental Information

351 Osborne Road, Loudonville, New York 12211 518.432.3991 518.432.3987 [email protected] www.albanydds.com ARWynnykiwDDS

Patient Name

Page 5: ARWynnykiwDDS Welcome!€¦ · 351 Osborne Road, Loudonville, New York 12211 518.432.3991 518.432.3987 smile@albanydds.com ARWynnykiwDDS When it comes to dentists, I know that you

'HUPDO�0XVFXORVNHOHWDO�!!�Past or Present

Yes NoSkin Rash � �Night Sweats � �Osteoarthritis � �Rheumatoid Arthritis � �$UWLˉFLDO�3URVWKHWLF�-RLQW � �Fibromyalgia � �

Yes NoConnective Tissue Disorders � �Systemic Lupis � �Congenital Anomaly/ Genetic Syndromes � �Have you taken or do you currently take bisphosphonates (i.e. Fosamax, Boniva)? � ������,I�VR��IRU�KRZ�ORQJ"

(QGRFULQH�!!�Past or Present

Yes NoDiabetes Type 1 � �Diabetes Type 2 � �Have you used/do you use Cortisone or other steroids? � �

*DVWURLQWHVWLQDO�!! Past or Present

Yes No*(5'�5HˊX[ � �Stomach/Intestinal Ulcers � �Colitis � �Persistent Diarrhea � �Hepatitis A � �Hepatitis B � �Hepatitis C � �-DXQGLFH � �

Yes NoCirrhosis � �Liver Disease � �Eating Disorder � �Anorexia � �Bulemia � �Malabsorption � �Celiac Disease � �Gluten Sensitivity � �

*HQLWRXULQDU\�!!�Past or Present

Yes NoFrequent Urination � �Kidney Problem � �Bladder Problem � �Dialysis � �

+HPDWRORJLF�!! Past or Present

Yes No%ORRG�7UDQVIXVLRQ � �Anemia � �Hemophelia � �

Yes NoLeukemia � �Sickle Cell Anemia � �Excessive/Irregular Bleeding � �

Neurologic >> Past or Present

Yes No9LVLRQ�3UREOHPV � �Glaucoma � �Earaches/Tinnitus/Ear Ringing � �Hearing Loss � �Severe Headaches/Migraines � ������)UHTXHQF\�Mild/Moderate Headaches � ������)UHTXHQF\�Fainting or Dizzy Spells � �Stroke � �Epilepsy � �Depression � �Anxiety/Nervousness � �Panic Attacks � �Phobias � �Seizures � �Convulsions � �Psychiatric treatment � �

3XOPRQDU\�!! Past or Present

Yes NoHay Fever � �Seasonal Allergies � �Sinus Trouble � �Asthma � �Chronic Cough � �

Yes NoEmphysema � �Chronic Bronchitis � �COPD � �Tuberculosis (TB) � �%UHDWKLQJ�'LIˉFXOWLHV � �

6OHHS�!! Past or Present

Yes NoApnea � �Do you use 2 or more pillows? � �

6XEVWDQFHV�!!'R�\RX�XVH� Now Past Never ��������/LVW�IUHTXHQF\�DQG�GXUDWLRQ�IRU�HDFK�

Tobacco/Cigarettes? � � �Chewing Tobacco? � � �Alcohol? � � �Recreational Drugs? � � �Intravenous Drugs? � � �Fen Phen? � � �

2WKHU�!! Past or Present'LVHDVH�3UREOHP�&RQGLWLRQ�1RW�/LVWHG���

,V�WKHUH�DQ\�RWKHU�PHGLFDO�RU�GHQWDO�LQIRUPDWLRQ�WKDW�\RX�IHHO�\RXU�GHQWLVW�VKRXOG�NQRZ�DERXW"������� Yes ��1R������,I�\HV��SOHDVH�GHVFULEH���

:RPHQ�!!

Patient Medical & Dental Information >> Page 2

Are you pregnant or possibly pregnant? Yes ��No �Are you using birth control pills? Yes ��No �Are you nursing? Yes ��No ������,I�VR��IRU�KRZ�ORQJ"�

,�DWWHVW�WKDW�WKH�DQVZHUV�,�KDYH�SURYLGHG�LQ�WKLV�TXHVWLRQDLUH�DUH�WUXH�DQG�DFFXUDWH�WR�WKH�EHVW�RI�P\�NQRZOHGJH�

Name 6LJQDWXUH� ����������'DWH�

3DWLHQW�RU�3DUHQW�*XDUGLDQ

Page 6: ARWynnykiwDDS Welcome!€¦ · 351 Osborne Road, Loudonville, New York 12211 518.432.3991 518.432.3987 smile@albanydds.com ARWynnykiwDDS When it comes to dentists, I know that you

351 Osborne Road, Loudonville, New York 12211

518.432.3991 518.432.3987

[email protected] www.albanydds.com

ARWynnykiwDDS

Page 1 of 2

Effective Date of Notice: September 1, 2013 -XVWLQ�0��7DUDQWR��+,3$$�2IˉFHU

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Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

Page 7: ARWynnykiwDDS Welcome!€¦ · 351 Osborne Road, Loudonville, New York 12211 518.432.3991 518.432.3987 smile@albanydds.com ARWynnykiwDDS When it comes to dentists, I know that you

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Page 8: ARWynnykiwDDS Welcome!€¦ · 351 Osborne Road, Loudonville, New York 12211 518.432.3991 518.432.3987 smile@albanydds.com ARWynnykiwDDS When it comes to dentists, I know that you

351 Osborne Road, Loudonville, New York 12211

518.432.3991 518.432.3987

[email protected] www.albanydds.com

ARWynnykiwDDS

I authorize A.R. Wynnykiw, DDS, PLLC to use and disclose protected health information in order to carry out treatment, payment activities, and healthcare operations.

I acknowledge that I have received or have been given the opportunity to receive a copy of A.R. Wynnykiw, DDS, PLLC’s Notice of Privacy Practices. This notice describes how A.R. Wynnykiw, DDS, PLLC may use and disclose my protected health information, certain restrictions on the use and disclosure of my healthcare information, and rights I may have regarding my protected health information.

Right to Terminate or Revoke Authorization:

You may revoke or terminate this authorization at any time by submitting a written revocation to the HIPAA Compliance 2IˉFHU�IRU�$��5��:\QQ\NLZ��''6��3//&��,�XQGHUVWDQG�WKDW�UHYRFDWLRQ�RI�WKLV�FRQVHQW�ZLOO�QRW�DIIHFW�DQ\�DFWLRQ�ZH�KDYH�taken in reliance on this consent before we received your revocation.

I understand and agree to the above terms:

Date Name of Patient Signature

In case of minor child or patient not able to speak or act on their own behalf:

Name of Patient Representative Signature

Relationship Date

Authorization of Use and Disclosure of Protected Health Information