exhc@ - dr. jaime gutierrez dds family and cosmetic dentistry · 2014. 5. 29. · jaime...
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![Page 1: Exhc@ - Dr. Jaime Gutierrez DDS Family and Cosmetic Dentistry · 2014. 5. 29. · JAIME GTJTIERRHZ,I}DS Please provide us rvith the follor'ving illfortnatton' It is neccssary as a](https://reader035.vdocument.in/reader035/viewer/2022081410/608fbc9eae1d9f2c014bcc9b/html5/thumbnails/1.jpg)
JAIME GTJTIERRHZ,I}DS
Please provide us rvith the follor'ving illfortnatton'It is neccssary as a part of any complete examinatir:n
to knor,v as mttch about yom general health in order
to prevent and/or eiiminate inlection and/or disease.
THIS INFORMATION WILL Bf, I{ELD S"TRICTI"Y COIqFIDENTIAL
Todav's Date: I I
Patients Name: Nickname:
L'ircle: Male / Female Date of Birth: l-l- Age :
Soc. Sec. #: i{ome Phoue #: i )
---Ho*re Address: __ _L-ity:
-.
. ----State: zip.
Mother/Guardian Information Exhc@Name: Name:
Work #: (
Celi Phone:
)__- Work #: ( )_-
F.-Mail:
Employer: Employer:
Soc. Sec. #: Soc. Sec. #:
,/I)rivers Lice nse #: X state: Drivers License ,r:
Persou Responsible For This Account:
Address and Phone if different then chiid:
Where and When are the Best Time To Reach Y*u?
Whorl May We Thank For Referring Yau to Us?
Other Fan:ii.v Me*rbers Seen by LIs?
>< slrte:
-Makirg Appointments:
Do You Have Dental Insurance? Yes / No Company: Policy #:
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TtME 9.37 t.M Jaime Gutierrez DDS
MEDICAL HI$TOftY
DATE 5IBI2O13
PAT i.]T NAMF Birth Date
Altii+ro:rdental pe.sonnel primariiytreatlneaieeinandaroundyoirrmouth,yorrftrsuthrs#pfidofyourentrrebody. Healthpr0hlefl$thaiycunrayhavr; . oi medjcation ihat yori may be taking coi-:ld l:ave an impo*a*l irterr*lationshjp with the d*ntjstry yru wili receiv*. Tha]lk you iot answering the
',. 'oul g quesl ors
Are you under a physician's care now? i.,.llave you ever been hc;spitalized or had a major operaiion? (.-'
Have you ever had a serous head or neck injury? ,_
A'e vr-:u tak ng a^v ,neCrcal ons D,l,s o' d.ugs?Do you lake, or have you laken, Fhen-Fen *r Redux? :
'riave r-ou ever taken Fosamax, Boniva, Actonel or anyother medicalrons containing bisphosphonates?'
Are you on a special diet? 1..
Do you use tobacco? ' "
Jc you ..se Jontror,ec subsia-ces?
PreUnaill.,Trying to get pregnant? t..
Yes , No
Are ycu allergic lo any of the follovring?
Taking orai c*niracept:ves? : Y*s Nr:
; C*deine Local Anesthetics Acrylic
Yesi .No
{g5 .. i No
Yes , -, No
Yes r.--, No
Yes .' : No
Yes ,. .: f.to
Yes- " No
Yes : liioYes' r No
lf yes, please explairi
lf yes. piease explain
lf yes, piease explain
lf yes, please explain
Nu rsing?
tvleia I
Yes r. _ No
. I Lat*x Si;lfa diugsAsp:r'rn , Penicillln
Other lf yes, prease explarn
Do ycu have. cr
/i1{JSilliV !oslir?eA:therrei's Disease
AaLaoh/iaxis
l',Ieria,/ini lna
tl1rfrt s/G]utArliFicral li*a4 Vai.re
Arlif 0ral Jr)rui
A5tf,r'fra
Biotid Disease
Eloo'J Tiansi!srcr:
ilr.iathrr'rg Problefii
Br!r$e Eas:iy
41,.,{ n cefCrt0r ri)::10.;ipy
ila're you had, any of
-,Yssles
rtl
. Yss
r Y€S:
.; Y*s'.:
'les
.rYesYes
] YES
-..t Yes'I
'fes
-., Yes
, Yes
Yes'r
Yes
Yesyes
the folioroing?
Co{isone Medrclne
Drug Addrciran
Easily B/rnded lfn:physe=aEpi epsy or Serit:resExc*ssive 3!eedrrgExcessive Thlrst i
Farnllng Sp8llslDjz.7rness i
F.eque.rt C$ugh l
Frequent Diarrhea r
Frequerl lieadacftesGenital H6rpes
Gla;comaHay Fever
Heari Ailacti Failure
lJeai M+rr":i.rr
Heert PacemakEr
l-lr6 rl Trou Lrl ei D isea sr
Hernrlphii:a
Hepalitis A ..,
HepatiirsBorC .,'Herpes ':
HrgF iJlooC irressuie .)
rligh Ch0lesteml ..,..1
i-live$ or Ra$h .l
HypoElycemia .,)
irieg'Jia{ HeafiDeat
Kldney Prcflleil':$
Leukemia
Liver Ol$*as6
Lcr,,Bicod Iressur* '
Lung D:sea$e
Mitial Valve Proiapse.
Osleoporosrs l
P,+rn in "ia"v Jolnts
Paraiiiy.ilid Olsease
Psychialric ca.e
fiadiation Treatments
Receilt W.eight l-sss
Re::al Dialysis
Rneurnali+ Fe'rer
Rheur,')41!sr$
Scarlet Feve{
Shing:es
Sick{e Cell Disease
Sinrs Trnuble
Spina Bifid*SlOErachltnt0stinal Disease
Strolif,Slvelilng ol LimbsThyroid Diseas€TcnsrlliiisTubeicLr!osisTLrrnors or GisvdtsUlc*rsVene.eal DiseaseYellow Jaundice
,, No
--, l.lo
.--, No
:: *o',., ilc., No
.- tio-' llo. lto
,, Xo,,.No
.r No
. . I'io
.. No
t*o' - l':o
r l(ia
Yes
Yes'Yes'YesYes
Yes'Yes
Ys.s
Yss '
Yes
Yes
Yes
Yes I
Ye$'Yes :
Yes
Yes
Yes
N*No
rNolNo
Ito, a'lc
lNc,NO:NO
..i No
,j No
I tl*.._'. No-r
Nr:
.,No, -
t'to
.No'r No
No
Yes l .: l'io
Yes .-') No
Yes .," 1r;g
Y+s '. .) NoYes r. NoYes t--, NcYes ,. , No
Ves -) No
Yel r .:
No
Yes!lNoYes : 1-,;o
Yes .' No
Yes'iNoYcs .
-, Nri
Yes , ,'; f{cYes
-. : No
Yes r...'NaYes
.: Na
Yes . ) tt*
Yes . . Nrl
Yes'lNoYes i".i N+
Yes 'l Ns
Yes r- i Nc
Ycs r -.'
No
Yes Nc)
Yes .i No
Yes : ', Nc
Yes I Nc
YeS - Na
Yes ,. , N.Yes . No
Yes - N<:
Yes hilo
Yes , ' l,icYe-c , N.
I
tlrlrJ sor"fsi Fevei B;i51ers
C+irq*rrial l{eei D}sc.dsl(;ir vrii s!iir s
ryesi'lNo:Yesr lNlo;Ygs :No
Hav* yJU ever had any serious illsess noi listed atlove?
{l,Jmffients
Yes hlc
I c the besi r:f my krowledge, the questioils on this fornr have been accurately ailswered. I understand that providin$ incorrect infcrr':.:ation can be
c,ange.cus io my (or'ratient'si health. lt is nry res;ronsibilrty tc inform the dental *fftce of any chanqes in medical status.
SiSNATIJRE OF PA'l1ENT PARENT, or GUARil:ANj DATE
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DENTAL.HISTONY
Your Current Dental Health is: fxcellent Good Fair Pocr
Why Have You Come To The D*ntist Today ?
Date af Last Dental Visjl: __ I I
FLEASE CTRCLE YE$ .l t*S rO ]HE rC.L!0Wrt{G:
Are You Currently in Pain ? YES / NO Mild I Moderate I $evere
Do You Like Your Smile ? YES / Nfl
Do Yaur Gums fver Bleed ? YES I NO
Have You Ever Had a Seri*us / Difficult Prnblem Associated with anyPrevious Dentai Work ? YE$ i NG
Do Y*u or Have You fver fxperienced Pain / Discnmfort in Your J*rn;JointiTMJ/TMD)? YES I NO
D* You Have Any Growths, Sare Spots, cr lnflamed Arsas i* orArnund Your Mouth ? YES / NO
Have You ilver Had A Local Anesthetic ? YES I NO
Do You Gri*d or C{ench Your Teeth 7 YfS I il}O
How Many Times a Week Do Y*u Floss ?
How Many Timss a Day Do Y*u Srush ?
What Type Used ?
What Type Used ?
I UNDERSTAND THAT THE INFORMATTON THAT I HAVE GIVTN TODAY IS COsNTCTTO THE BE$T GF MY KNCIWLEDGE. I ALSO UNDERSTAND THAT IT IS MY HESPCNS:BILITY
TO INTOFM THIS OFFICE OT ANY CHANGIS IN MY MEDICAL STATUS.
I AUTHORTZT THT DINTAI STAFF TO PREFORM AI{Y NTCESSATY DTNTAL $ERVICTSWITH MY INTORMID CON$HNT T1-{AT i MAY NTED ilURtNG
*IAGNOSIS ANN TREATMENT1
tlSIGNATUilT: PATI[NT. PAHTNT OR GUARDI,AN DATE
CIUTT OFFICff IS COMMITIED TA MEETING OR EXCEEilTI{G THE STA}|],,,ARilS OF
II{FECTI2N C9NTR2L IqL4NDATED BY OSttA, TT-IE CDC, ANI} THE ADA.
DOCTOR SIGNATURE DATE
tiVdITNESSED BY:
r DATI
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Appendix 2.9
Authorization Form for Use or Disclosure of Patient lnformation
Patient Name:
Patient's Date of Birth: Patient's Chart No.:
I hereby authorize the use and disclosure of the patient information as described below. I
understand that information disclosed pursuant to this authorization may be subject toredisclosure by the recipient and may no longer be protected by HIPAA Privacy regulations.
Specific description of the patient information to be used or disclosed:lnsuronce benefits. claim informatian. secondarv insurance coordination. eliqibilitv. ond/or otthe request of an individual.
Purpose(s) of this use or disclosure:lnsurance Benefits, Cloims. Eliqibilitv purooses
At the request of the individual
I authorize the following person(s) to make this use or disclosure:
Dr. Jaime Gutierrez ond Staff Members
The following person(s) may receive this patient information:
Stoff Responsible for potient authorizotions
I understand that I may revoke this authorization at any time, and that my revocation is noteffective unless it is in writing and received by the dental practice's Privacy Official at Dr.loimeGutierrez DDS Familv and Cosmetic Dentistl ot 304 Federal Road Suite 277 Brookfield CT
068(M. lf I revoke this authorization, my revocation will not affect any actions taken by thedental practice before receiving my written revocation.
I understand that I may refuse to sign this authorization, and that my refusal to sign in no wayaffects my treatment, payment, enrollment in a health plan, or eligibility for benefits.
This authorization expires on the followinq date, or when the following event occurq:None.
Signature of Patient or Patienfs Personal Representative:
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Appendix 2.3.2
Acknowledgement of Receipt of Notice of Privacy Practices
Dr Jaime Gutierrez DDS
304 Federal Road Suite 217Brookfield CT 05804
* You May Refuse to Sign This Acknowledgment*
I have read the copy of this office's Notice of Privacy Practices which is laminated in the officewaiting room. lf requested, I have received a copy from the office.
Print Name:
Signature:
Date:
By checking the box below you are grantint the office permission to use your name in our referral
For Office Use OnlY
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices,
but acknowledgement could not be obtained because:
*lndividual refused to sign
*Comm unications ba rriers prohibited obtainin! the acknowledgement
*An emergenry situation prevented us from obtaining acknowledgement
*Other (Please Specify)
Reproduction of this material by dentists and their staff is permitted. Any other use, duplication or distribution by any other party requires the
prior written approval of the American Dental Association. This material is for general reference purposes only and does not constitute legal
advice. lt covers only HIPAA, not other federal or state law. Changes in applicable laws or regulations may require revision. Dentists should
contact qualified legal counsel for legal advice, including advice pertaining to HIPAA compliance, the HITECH Act, and the U.S. Department of
Health and Human Services rules and regulations.
O 2010, 2013 American Dental Association. All Rights Reserved.
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f f Personal Representative;
Print Name:
Signature: Relationship to Patient:
For office use only: Copy a{ signed authorization provided to the individual:
Date:lnitials:
Reproduction of thi$ material by drntis$ and their sta$ is permitted. Any olher use, duplication or dislribution by any other party requires the
prior rdritteil approval of the An:erican Dental A$sociation. This material is fur general reference purposes only afld does not constitute legal
advice. lt covers cnty HiPAA, nst ether federal or state law. Changes in applicablt laws or regulation$ rnay requi.e rtvisiort. Dentl$s should
contact qualified legal counsel frr le6al advic+, including advice pertainlng to HlpfiA complianc€, the HITlCil Art, and the U.5" Departme*t of
llealth and Ftuman Services rules and regulati*nr.
O 2010, 2013 Afiericafl Dental Asso€iation. All Rights Reserved