HEALTH HISTORY FOR DENTAL SERVICES

Patient's Name: ___________________________________________________________________________________________________ (First) (Middle) (Last) (Date of Birth) (Age) (Social Security Number)

Home address:____________________________________________________________________________________________________

(Street) (City) (Zip Code) (Telephone)

1. What kind of dental problem do you have? 8. Have you ever had abnormal bleeding associated with

________________________________________________________ previous extractions, surgery, or trauma? – Yes __No__

________________________________________________________ a) Have you ever required a blood transfusion?Yes _No__

b) Do you have a blood clotting disorder----------Yes _No__

2. Has there been any change in your health within the past If so, explain: __________________________________

year? -----------------------------------------------------Yes __ No__

9. Have you had radiation treatment for a tumor, or other

3. Are you under the care of a physician ------------ Yes __ No__ condition of your mouth or lips? ------------------Yes--No

4. The name and phone number of my physician is:

____________________________________________________ 10. Do you take any blood thinners? -----------------Yes__No____

Do you take any bisphosphonates?----------------Yes__No____

5. Have you had any serious illness, accident or operation? Please list all medications:______________________________

-------------------------------------------------------------Yes __ No__ _____________________________________________________

If so, what was the illness, accident or operation: _____________________________________________________

____________________________________________________ _____________________________________________________

____________________________________________________ 11. Are you allergic or have you reacted adversely to:

a) Local anesthetics ----------------------------- Yes __ No__

6. Are you required to PRE-MEDICATE before any

dental treatment? YES _____NO______ b) Penicillin or Amoxicillin --------------------Yes __ No__

If YES, reason____________________ c) Sulfa drugs ------------------------------------Yes __ No __

d) Barbiturates, sedatives, or sleeping pills Yes __ No __

7. Do you have or have you had the following diseases or problems: e) Aspirin -----------------------------------------Yes __ No __

a) Rheumatic Fever or Rheumatic heart disease. Yes __No __ f) Iodine --------------------------------------------Yes __ No __

b) Congenital Heart Lesions --------------------------Yes __No __ g) Codeine ----------------------------------------- Yes __ No __

c) Cardiovascular Disease h) Latex --------------------------------------------Yes __ No __

1) Heart Attack ----------------------------------------Yes __ No __ i) Other ____________________________________

2) Heart Trouble ---------------------------------------Yes __ No __

3) Coronary Insufficiency---------------------------- Yes __ No __ 12. Do you have any disease, condition or problem not listed

4) Coronary Occlusion---------------------------------Yes __ No __ above that you should let us know about? --Yes __ No __

5) High Blood Pressure -------------------------------Yes __ No __ If so, please explain ______________________________

6) Arteriosclerosis--------------------------------------Yes __ No __ _____________________________________________________

7) Stroke -------------------------------------------------Yes __ No __ ________________________________________________

8) Heart Murmur--------------------------------------Yes __ No __

9) Mitral Valve Prolapse---------------------------- -Yes __ No __

d) Asthma or Hay Fever--------------------------------Yes __ No __ WOMEN

e) Fainting spells or seizures---------------------------Yes __ No __ 13. Are you pregnant? -------------------------------Yes __ No __

f) Diabetes Type 1____Type2____--------------------Yes __ No __

g) Hepatitis A____B____C_____ --------------------- Yes __ No __ CHILDREN

h) Liver Disease ---------------------------------- ------- Yes __ No __ 14. Any prenatal or birth complications? ------- Yes __ No _

i) Tuberculosis-------------------------------------------- Yes __ No __ If yes please explain: ____________________________

j) Venereal Disease-------------------------------------- Yes __ No __

k) Human Immune Deficiency Virus (HIV/AIDS) Yes __ No __ 15. List any history of tobacco, alcohol or drug use:

l) Other___________________________________________ ______________________________________________

___________________________________________ ______________________________________________

To the best of my knowledge, the forgoing medical history questions have been accurately answered.

Name______________________________________ Relationship to patient _________________________

Signature________________________________________________________Date ____________________

Dentist Signature_____________________________________________________________________ Date____________________

Reviewed by Assistant _______ Date __________ Assistant ________ Date ___________ Assistant _______ Date ______________ Initial Initial Initial

Kodak Dental Care

Your Privacy Is Important to Us

Acknowledgement of Notice of Privacy Policies

If requested, I may receive a copy of the Notice of Privacy Practices of Kodak Dental Care, PLLC. I hereby

authorize, as indicated by my signature below, Kodak Dental Care to use and to disclose my protected

health information for any necessary clinical, financial, and insurance purpose, as authorized in the Patient

Consent form.

_________________________________ _________________________________

Patient’s Name Signature (Guardian if patient is a minor)

_____________________

Date

Please check your preferred means of communication:

□ You may contact me at my home telephone number _____________________________

□ You may contact me on my mobile telephone number ____________________________

□ You may contact me on my work telephone number _____________________________

□ You may send me an email at: ______________________________________________

□ Other __________________________________________________________________

Please list authorized persons with whom we may discuss your Protected Health Information (PHI) in

addition to custodial parents and legal guardians:

1. _____________________________________________________Date Added / Removed:__________

2. _____________________________________________________Date Added / Removed: __________

3. _____________________________________________________Date Added / Removed: __________

4.______________________________________________________Date Added / Removed: _________

5.______________________________________________________Date Added / Removed: _________

For Office Use Only:

We attempted to obtain written acknowledgement of our Notice of Privacy Practices,

but acknowledgement could not be obtained because:

□ Individual refused to sign

□ Communication barriers prohibited obtaining the acknowledgement

□ An emergency situation prevented us from obtaining the acknowledgement

□ Other (Please Specify) _____________________________________________

Staff Person Initials ___________

PATIENT CONSENT

Clinical

I authorize the dentists of Kodak Dental Care to perform all recommended treatment.

I authorize the Practice to take radiographs, study models, photos, and other diagnostic aids

or materials (collectively, “Diagnostic Material”) as needed to make a thorough diagnosis. I

authorize that such Diagnostic Material may be released to third-party payors and/or other

health professionals.

I authorize the use of anesthetics, sedatives, and other medication, as needed, and am fully

aware that using anesthetic agents involves certain risks, including but not limited to redness

and swelling of tissues, pain, itching, vomiting, dizziness, miscarriage, cardiac arrest,

drowsiness, and/or lack of coordination.

My initials by each statement indicate my understanding of our broken appointment policy:

Because reserved appointments require operatory and staff assignment, equipment and

instrument setup along with administrative and/or insurance pre-planning, please pay close

attention to the following requirements:

• We do require a 24 hour business day notice when an appointment has to be

cancelled or rescheduled.

• We will ask you to confirm your appointment. Please do so when prompted through

the messaging system or you may phone the office.

• We do reserve the right to charge for a broken appointment. After two missed

appointments per family, the family is subject to same day only appointments or

dismissal from the practice.

Insurance

I authorize the Practice to release to staff, hospitals, health care service plans, insurance

companies, self-insurers or their representatives, any and all information, records, and other

Diagnostic Material about my medical history, services rendered, or recommended treatment.

I authorize the Practice to submit claims for payment for services rendered or pre-

authorizations necessary to my insurance company, on my behalf and in my name listed as

“signature on file” and assign to the Practice the insurance benefits providing assignment is

accepted. I am responsible for payment regardless of coverage provided.

Financial

I am responsible for payment for all services rendered on my behalf. I understand that

payment is due when services are rendered. Should my account become delinquent, I will be

responsible for all additional collection costs, including reasonable attorney fees.

I have read this Patient Consent and agree to all terms and conditions herein.

Patient’s or Guardian’s (if minor) Signature: ______________________ Date: ___________

COVI D-L9 Pa ndem ic Denta I Treatment Consent Fo rm

Name of Patient:

Name of Dentist:

Name of office:

you have elected to receive dental care during the events of the COVID-19 Nationa! Emergency. We are providing this

special consent, in addition to any procedure-specific consent that you may receive, because of the unique circumstances

of the current Covid-19 pandemic. Some considerations to keep in mind as you seek dental treatment under these unique

circu mstances:

. Although dental procedures often involve a risk of infection, the ongoing community transmission of the Covid-19

virus creates additional risks from being in the proximity of dentists, patients, or staff that we want you to seriously

consider before engaging in treatment.. Social distancing of 6 feet or more is NOT POSSIBLE during dental treatments, which may increase the chances of

COVID-19 transmission.. lt may be necessary to use aerosol-generating equipment during dental procedures. This equipment may increase

the potential for spreading the disease. lt is estimated that aerosol droplets can linger in the air for minutes to

hours and have the potential to transmit the COVID-1-9 virus'

o As dental professionals and public officials around the country have been discussing, risks related to COVID-19 must

be weighed against the potential detrimental effects of postponing dental treatment, as dental health is

inextricably linked to overall health.

o We are available to provide dental care if you decide to proceed with dental treatment at this time.

o We are following our standard infection protocols which may limit the spread of the disease, but there is a still apossibilitv of transmission to vou (and to others vou come into contact with after leaving this officel of the CoVID-

19 virus which can cause serious health problems. including but not limited to. severe respiratorv problems. hish

fevers and death.

Here is what we are doing to protect you the patient, team members and ourselves:

. We are following safety directives from your state as a way to limit patient and staff exposure to this virus.

. We engage in a daily office preparation safety routine.

. We conduct patient and staff COVID-19 screening'

. We utilize personal protective equipment for office staff and patients and provide training to our staff on the proper

methods of putting on and removing this equipment'. We implement cleaning and disinfecting protocols before the office opens and between patients.

. All team members follow applicable guidelines for sterilization and surface disinfection procedures.

o We try to avoid or minimize dental procedures involving aerosols and utilize additional personal protective

equipment and protocols for those procedures which may involve aerosols.

My lnitials by each statement indicate my understanding and acceptance:

[_l I understand that the COVID-19 Virus has a long incubation period during which carriers of the virus may not show

symproms out may still be highly contagious. lt is impossible to determine who has it and who does not, given

the current limits in the virus testing.

I understand that due to the frequency of visits of other dental patients, the characteristics of the virus and

characteristics of dental procedures that I have an elevated risk of contracting the virus by virtue of engaging in

dental treatments and by virtue of simply being in a dental office.

I understand that there is still much we do not know about the COVID-19 Virus and, therefore, there may be risks

that are yet unknown.

Date:

trtrT

COVI DL9 Pa ndemic Denta I Treatment Consent Fo rmI confirm that I am NOT presenting with any of the following symptoms of COVID-L9 listed

below:

. Fever > 100.4

. Shortness of breath or difficulty breathing

. Dry Cough

. Chills

. Reseated shaking with chills

. Muscle pain

. Headache

. Sore throat

. New loss of taste and/or smell

n I understand that travel by air, bus or train significantly increases my risk of contracting and transmitting theI I COVTD-19 virus, and I verify that I have not traveled domestically within the United States by commercial airline,

bus, or train within the past 14 days.

I verify that I have not traveled outside ofthe United States in the past 14 days to countries that have been affected

by the COVID-L9 virus.

I understand that the CDC currently recommends social distancing of at least 6 feet or more under many

circumstances and that social distancing of 6 feet or more is NOT POSSIBLE during dental treatments.

I understand that additional consent is required for the specific treatment being provided during this dental

emergency.

The safety and well-being of our patients continues to be our primary concern. We will continue to monitor the status of

COVID-19 nationally and within our community and update office policy as needed to continue to provide dental services

to our community.

I have read this entire document, and I knowingly and willingly consent to have dental

treatment during the COVID-19 pandemic, despite the risks discussed in this consent.

Patient's lnitials

Signature of Patient or Signature of Patient's Parent/ Legal Guardian

Name of Patient (print) or Name of Patient's Parent/ Legal Guardian (print)

Signature of Witness Name of Witness (print)

Date of Signing