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 #:

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

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

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:

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.

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