We are pleased to welcome you to our office.  By contacting our office, you have demonstrated that you are vitally interested in saving your teeth.  We want you to know that you can expect the best periodontics has to offer in an environment of caring, concern and compassion.  (We realize that going to a new dentist can be a bit unsettling and that this transition is difficult.  We hope that once you have met us that soon you will feel more at ease).  Our goal will be to provide you with the best periodontal care.    Examination  We will examine your teeth and gums to determine the extent of your periodontal disease problems.  We will evaluate the gums for signs of bleeding, swelling, softness and recession.  We will check your teeth for movement and sensitivity, as well as evaluate your bite.  We will measure your gums with a periodontal probe to detect if there are any pockets and the extent of infection.    Fees and Dental Insurance  We do request that payment be made at the time of your initial office visit.  Although we do not participate with any insurance companies, our office will do everything possible to help you understand and make the most of your dental insurance benefits.  We realize that dental insurance is complex.  As a courtesy, our office will complete and submit dental insurance forms and predetermine benefits to achieve the maximum reimbursement to which you are entitled.  Upon receipt of an insurance payment, any balance due is billed to you.  A refund is issued when you have a credit on your account.    For your convenience, we are enclosing paperwork that you may complete and bring to your first appointment.    We look forward to meeting you on   ____________________________________________________________________________ 

   

6105 Transit Road Suite 120 East Amherst, NY 14051 (716)626‐4427 3008 Military Road Niagara Falls, NY 14034 (716)626‐4427 

Roger Anderson DDS, MS Cornerstone Periodontics and Dental Implants

Medical History Form Patient Name: ___________________________________ Date Created: ___________________ Birth Date: ____________________ Although dental personnel primarily treat the area in and around you mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions. Are you under the care of a general dentist? If yes, please describe. O Yes O No _____________________________________________________________________________ Are you under a physician’s care now? If yes, please describe. O Yes O No _____________________________________________________________________________ Have you ever been hospitalized or had a major operation? O Yes O No _____________________________________________________________________________ Have you ever had a serious head or neck injury? O Yes O No _____________________________________________________________________________ Are you taking any medications, pills, or drugs? If yes, please list. O Yes O No _____________________________________________________________________________ Do you take, or have you taken, Phen-Fen or Redux? O Yes O No _____________________________________________________________________________ Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? O Yes O No _____________________________________________________________________________ Are you on a special diet? O Yes O No _____________________________________________________________________________ Do you use tobacco? If yes, how often? O Yes O No _____________________________________________________________________________ Are you taking aspirin? If yes, how much? O Yes O No ______________________________________________________________________________

Please See Reverse

General Medical Questions Do you use controlled substances? If yes, please describe. O Yes O No ______________________________________________________________________________ Women: Are you… O Pregnant/Trying to get pregnant? O Nursing? O Taking oral contraceptives? Are you allergic to any of the following? O Aspirin O Antibiotics O Codeine O Acrylic O Medications O Latex O Sulfa Drugs O Local Anesthetics O Iodine If yes to any of the above, please describe. ___________________________________________ ______________________________________________________________________________ Do you have, or have you had, any of the following? AIDS/HIV POSITIVE O Yes Cortisone Medicine O Yes Hemophilia O Yes Radiation Treatments O Yes Alzheimer’s Disease O Yes Diabetes O Yes Hepatitis A O Yes Recent Weight Loss O Yes Anaphylaxis O Yes Drug Addiction O Yes Hepatitis B or C O Yes Renal Dialysis O Yes Anemia O Yes Easily Winded O Yes Herpes O Yes Rheumatic Fever O Yes Angina O Yes Emphysema O Yes High Blood Pressure O Yes Rheumatism O Yes Arthritis/Gout O Yes Epilepsy or Seizures O Yes High Cholesterol O Yes Scarlet Fever O Yes Artificial Heart Valve O Yes Excessive Bleeding O Yes Hives or Rash O Yes Shingles O Yes Artificial Joint O Yes Excessive Thirst O Yes Hypoglycemia O Yes Sickle Cell Disease O Yes Asthma O Yes Fainting Spells/DizzinessO Yes Irregular Heartbeat O Yes Sinus Trouble O Yes Blood Disorder O Yes Frequent Cough O Yes Kidney Problems O Yes Spina Bifida O Yes Blood Transfusion O Yes Frequent Diarrhea O Yes Leukemia O Yes Stomach/Intestinal O Yes Breathing Problems O Yes Frequent Headaches O Yes Liver Disease O Yes Stroke O Yes Bruise Easily O Yes Genital Herpes O Yes Low Blood Pressure O Yes Swelling of Limbs O Yes Cancer O Yes Glaucoma O Yes Lung Disease O Yes Thyroid Disease O Yes Chemotherapy O Yes Hay Fever O Yes Mitral Valve Prolapse O Yes Tonsilitis O Yes Chest Pains O Yes Heart Attack/Failure O Yes Osteoporosis O Yes Tuberculosis O Yes Cold Sores/Fever Blisters O Yes Heart Murmur O Yes Pain in Jaw Joints O Yes Tumors/Growths O Yes Congenital Heart Disease O Yes Heart Pacemaker O Yes Parathyroid DiseaseO Yes Ulcers O Yes Convulsions O Yes Heart Trouble/Disease O Yes Psychiatric Care O Yes Venereal Disease O Yes Yellow Jaundice O Yes Have you had any serious illness not listed above? ____________________________________________________ Comments: To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status. Signature of Patient, Parent or Guardian: ____________________________________________ Date: _______________

PATIENT REGISTRATION

ID: Chart ID:

First Name:

Patient Is: • Policy Holder • ResponsWe Party

Responsible Party (If someone other than the patient)

First Name:

Address:

Last Name:

Preferred Name:

Last Name:

Middle Initial:

Middle Initial:

Address 2:.

City, State, Zip:

Home Phone: _

Birth Date:

Work Phone:

Soc. Sec:

Ext

Pager.

Cellular:

O Responsible Party Is also a Policy Holder for Patient O Primary Insurance Policy HokJer O Secondary Insurance Policy Holder

Patient Information

Address: Address 2:

City, State, Zip:

Home Phone:

Sex: O Male

Birth Date:

E-Mail:

Work Phone: Ext:

Pager

Cellular

O Female

Age:

Marital Status:

_ Soc. Sec: .

OMarred O Single O Divorced OSeparated Qmio^

Section 2

Employment Status:

Student Status:

Medicaid ID:

• I would like to receive conespondences via e-mail.

- • Section 3

O Full Time

O Full Time

O Part Time

O Part Time

O Retired

Pref. Dentist:

Employer ID:.

Carrier ID: _

Pref. Pharmacy:

Pref.Hyg.:

Nickname:

Fax*

Physician Ph #:

Referred by:

Emergency contact:

Contact's Ph #:

Primary Insurance Information

Name of Insured:

Insured Soc. Sec:

Employer _ _ _ _ _

Relationship to Patient: O Self O Spouse Q Child Q Other

Insured Birth Date:

Address

Address 2

Cly, State, Zip

Rem. Benefits:

Ins. Company:

Address:

Address 2:

Cly, State, Zip:

.00 Rem. Deduct: .00

Secondary Insurance Information

Name of Insured: _ _ _

Insured Soc. Sec:

Employer.

Relationship to Patient: O Self O Spouse Q Child Q Other

Insured Birth Date:

Address:

Address 2:

Cly, State, Zip:

Rem. Benefits:.

Ins. Company:

Address:

Address 2

Cly, State, Zip

.00 Rem. Deduct: .00

  

We are committed to providing you with the best possible care and would discuss our professional fees with you at any time.  Your clear understanding of our Financial Policy is important to our professional relationship.    You as the patient are responsible for the timely payment of your account.    Dental Insurance is a contract between you and your insurance company.  We will file insurance claims and a pre‐determination of benefits as a courtesy to our patients.  We will not become involved in disputes between you and your insurance company regarding deductibles, co‐payments, covered charges, secondary insurance and “usual and customary” fees.  Pre‐treatment estimates ARE NOT a guarantee of payment due to yearly maximums, policy changes and/or deductibles.    Full payments or any co‐payments are due at the time of service.    The office of Dr. Roger Anderson will not be held responsible or be found liable for any unpaid balance on your account that you or your insurance company agreed to pay.    I have read the above information, therefore, I agree to be solely responsible for any and all unpaid balance(s) on my account.    Name Printed ___________________________________________  Name Signed ____________________________________________  Date _______________________________  

   

6105 Transit Road Suite 120 East Amherst, NY 14051 (716)626‐4427 3008 Military Road Niagara Falls, NY 14034 (716)626‐4427 

Medical Information Release Form

Name: _______________________________ Date of Birth: _____/______/______

[ ] I authorize the release of information including the diagnosis, records,

examination rendered to me and claims information. This information may be

released to:

[ ] Spouse __________________________________________

[ ] Children _________________________________________

[ ] Other ____________________________________________

[ ] Information is not to be released to anyone.

This Release of Information will remain in effect until terminated by me in writing.

Messages

Please call: [ ] home ____________ [ ] work ____________ [ ] cell ______________

If unable to reach me:

[ ] you may leave a detailed message

[ ] please leave a message asking me to return your call

[ ] ___________________________________________________

The best time to reach me is (day) __________________ between (time) __________

[ ] I have read and understand the Hippa Notice of Information Practices and

Privacy Statement.

Signed: _____________________________________________ Date: ____/____/____

Witness: ____________________________________________ Date: ____/____/____