Health History Form

Email Address

Today's Date

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Patient Information

First Name

Last Name

Middle Initial

Home Phone

Cell Phone

Work Phone

Preferred Method of Contact

Phone

Text

Mailing Address

City

State

Zip

Height

Weight

Date of Birth

Gender

Marital Status

Social Security #

Occupation

Emergency Contact

How did you hear about us?

If you are completing this form for another person, what is your relationship to that person?

Your Name

Relationship

Home Phone

Cell Phone

Dental Information

Are your teeth sensitive to cold, hot, sweets or pressure?

Yes

Does food or floss catch between your teeth?

Yes

Is your mouth dry?

Yes

Have you had any periodontal (gum) treatments?

Yes

Have you ever had orthodontic (braces) treatment?

Yes

Have you ever had any problems associated with previous dental treatment?

Yes

Is your home water supply fluoridated?

Yes

Do you drink bottled or filtered water?

Yes

If yes, how often?

Daily

Weekly

Occasionally

Do you have earaches or neck pains?

Yes

Do you have any clicking, popping, or discomfort in the jaw?

Yes

Do you brux or grind your teeth?

Yes

Do you have sores or ulcers in your mouth?

Yes

Do you wear dentures or partials?

Yes

Do you participate in active recreational activities?

Yes

Have you ever had a serious injury to your head or mouth?

Yes

Are you currently experiencing dental pain or discomfort?

Yes

Chief Complaint

Date of your last dental exam

What was done at that time?

Date of last dental x-rays

Reason for visit

Medical Information

Are you currently under the care of a physician?

Yes

Physician Name

Phone Number

Address / City / State / Zip

Are you in good health?

Yes

Has there been any change in your general health within the past year?

Yes

If yes, what condition is being treated?

Date of last physical exam

Do you use controlled substances (drugs)?

Yes

Do you use tobacco (smoking, snuff, chew, bidis)?

Yes

If so, how interested are you in stopping?

Very

Somewhat

Not Interested

Do you drink alcoholic beverages?

Yes

If yes, how much alcohol did you drink in the last 24 hours?

Have you had a serious illness, operation or been hospitalized in the past 5 years?

Yes

If yes, what was the illness or problem?

Do you take any blood thinners?

Yes

Do you take aspirin on a regular basis?

Yes

Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Yes

If yes, please list all medications, including vitamins, natural or herbal preparations and/or diet supplements

Women Only Are you:

Pregnant?

Yes

Number of weeks

Taking birth control pills or hormonal replacements?

Yes

Nursing?

Yes

Have you ever had an orthopedic total joint (hip, knee, elbow, finger) replacement?

Yes

If yes, date

If yes, have you had any complications?

Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.

Local anesthetics

Yes

Aspirin

Yes

Penicillin or other antibiotics

Yes

Barbiturates, sedatives, or sleeping pills

Yes

Sulfa drugs

Yes

Codeine or other narcotics

Yes

Metals

Yes

Latex (rubber)

Yes

Iodine

Yes

Hay fever / seasonal

Yes

Animals

Yes

Food / Other

Yes

If yes, please specify

Please mark "Yes" if you have (or have had) any of the following diseases or problems.

Heart murmur

Yes

Mitral valve prolapse

Yes

Artificial heart valves

Yes

Rheumatic fever

Yes

Cardiovascular disease

Yes

Angina

Yes

Arteriosclerosis

Yes

Congestive heart failure

Yes

Coronary artery disease

Yes

Damaged heart valves

Yes

Heart attack

Yes

Low blood pressure

Yes

High blood pressure

Yes

Congenital heart defects

Yes

Pacemaker

Yes

Rheumatic heart disease

Yes

Abnormal bleeding

Yes

Anemia

Yes

Blood transfusion

Yes

If yes, date

Hemophilia

Yes

AIDS or HIV infection

Yes

Arthritis

Yes

Autoimmune disease

Yes

Rheumatoid arthritis

Yes

Systematic lupus erythematosus

Yes

Asthma

Yes

Bronchitis

Yes

Emphysema

Yes

Sinus trouble

Yes

Tuberculosis

Yes

Cancer / Chemotherapy / Radiation treatment

Yes

Chest pain upon exertion

Yes

Chronic pain

Yes

Diabetes type I or type II

Yes

Eating disorder

Yes

Malnutrition

Yes

Gastrointestinal disease

Yes

GE Reflux / persistent heartburn

Yes

Ulcers

Yes

Thyroid problems

Yes

Stroke

Yes

Glaucoma

Yes

Hepatitis, jaundice, or liver disease

Yes

Epilepsy

Yes

Fainting spells or seizures

Yes

Neurological disorders

Yes

If yes, please specify

Gag Reflex Sensitivity

Yes

Sleep disorder

Yes

Mental health disorders

Yes

If yes, please specify

Recurrent infections

Yes

If yes, type of infection

Kidney problems

Yes

Night sweats

Yes

Osteoporosis

Yes

Persistent swollen glands in neck

Yes

Severe headaches / migraines

Yes

Severe / rapid weight loss

Yes

STDs / STIs

Yes

Excessive urination

Yes

ADD

Yes

ADHD

Yes

Sensory Processing Disorder

Yes

Oral Sensory Sensitivity

Yes

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Yes

Do you have any disease, condition, or problem not listed above that you think we should know about?

Yes

If yes, please explain

Pharmacy Information

Pharmacy Name

Pharmacy Phone

Pharmacy Address

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Download Printable Version

HIPAA Consent Form

General Information

Name

Date of Birth

Street Address

City

State

Zip code

Consent & Notice of Privacy Practices

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us by phone or email.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Download Printable Version

Patient Screening Form

General Information

Patient Name

Today's Date

Patient Screening

Have you/they recently been vaccinated for COVID-19?

Yes

Have you/they recently received a booster shot for COVID-19?

Yes

If yes, when was your/their last shot?

Which vaccination did you/they receive?

Have you/they recently been tested for COVID-19?

Yes

If yes, please specify test date.

Have you/they tested positive for COVID-19?

Yes

Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?

Yes

Are you/they having shortness of breath or other difficulties breathing?

Yes

Do you have a cough?

Yes

Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?

Yes

Have you/they experienced recent loss of taste or smell?

Yes

Are you/they in contact with any confirmed COVID-19 positive patients?

Patients who are well but who have a sick family member at home with COVID-19 should consider postponing elective treatment.

Yes

Is your/their age over 60?

Yes

Do you/they have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?

Yes

Have you/they traveled in the past 14 days to any regions affected by COVID-19?

(as relevant to your location)

Yes

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

Download Printable Version

Office Benefits and Policies Form

Assignment of Insurance Benefits, Payment Policy, and Payment Options

The policy of MCDental Care, PLLC is to be paid directly by your insurance company. By signing this form, you authorize direct payment to MCDental Care, PLLC and assume responsibility of all non-covered services or provider charges that may exceed insurance payment.

Initial

Our payment policy is as follows:

Payment is required the day services are rendered.
Returned checks are subject to a $36 NSF fee and may be subject to an additional collection fee.
Balances over 30 days may be subject to additional collection action.
All accounts not paid within 90 days will be sent to a collection agency.

For your convenience, we offer several payment options. Please read the following information:

Cash or Check.
Visa, MasterCard, or American Express.
Interest-free or extended financing through CareCredit.

Credit balances on your MCDental Care, PLLC account are subject to reimbursement. A check will be issued by MCDental Care, PLLC within thirty days of your request for a refund. However, processing/transaction fees will be deducted from any refund in which credit balances occur due to a personal overpayment by credit card or CareCredit.

As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. This dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1.5% per month (18% annum) on any unpaid balance will be charged to the patient on all accounts exceeding 30 days past due, unless written financial arrangements are satisfied.

Initial

MCDental Care, PLLC can only estimate insurance payments and laboratory costs. All dental services not paid by insurance are charged directly to the patient. Any unpaid balance, as well as attorney fees, court costs, and collection costs incurred by collection and enforcement of a debt are the responsibility of the patient.

Cancellation Policy

Initial

MCDental Care, PLLC updated cancellation policy: After hours, please contact Dr. Dziurgot on her cell (586.823.0422) to reschedule. There will be a $35 fee for any cancellation within 2 business days. If two appointments are cancelled or no showed within 2 business days notice within a 12 month period, MCDental Care, PLLC will place your name on a call list. Three appointments without 2 business days notice within a 12 month period will result in permanent dismissal from the practice.

Patient Acknowledgement and Consent for Services

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

I have had full opportunity to read and consider the contents of this form and your Notice of Privacy practices. I understand that by signing below, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or her assignee, at the time said services are rendered. I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder.

I grant my permission to you or your assignee to telephone me at home or at my work to discuss matters related to this form.

I have read the above conditions of treatment and payment and agree to their content.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.