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Health History Form

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

Preferred Method of Contact

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

Dental Information

Are your teeth sensitive to cold, hot, sweets or pressure?
Does food or floss catch between your teeth?
Is your mouth dry?
Have you had any periodontal (gum) treatments?
Have you ever had orthodontic (braces) treatment?
Have you ever had any problems associated with previous dental treatment?
Is your home water supply fluoridated?
Do you drink bottled or filtered water?
If yes, how often?
Do you have earaches or neck pains?
Do you have any clicking, popping, or discomfort in the jaw?
Do you brux or grind your teeth?
Do you have sores or ulcers in your mouth?
Do you wear dentures or partials?
Do you participate in active recreational activities?
Have you ever had a serious injury to your head or mouth?
Are you currently experiencing dental pain or discomfort?

Medical Information

Are you currently under the care of a physician?
Are you in good health?
Has there been any change in your general health within the past year?
Do you have a history of chemical dependency?
Are you in recovery?
Do you use controlled substances (drugs)?
Do you use tobacco (smoking, snuff, chew, bidis)?
If so, how interested are you in stopping?
Do you drink alcoholic beverages?
Have you had a serious illness, operation or been hospitalized in the past 5 years?
Do you take any blood thinners?
Do you take aspirin on a regular basis?
Are you taking or have you recently taken any prescription or over the counter medicine(s)?

Women Only Are you:

Pregnant?
Taking birth control pills or hormonal replacements?
Nursing?
Have you ever had an orthopedic total joint (hip, knee, elbow, finger) replacement?

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

Local anesthetics
Aspirin
Penicillin or other antibiotics
Barbiturates, sedatives, or sleeping pills
Sulfa drugs
Codeine or other narcotics
Metals
Latex (rubber)
Iodine
Hay fever / seasonal
Animals
Food / Other

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

Heart murmur
Mitral valve prolapse
Artificial heart valves
Rheumatic fever
Cardiovascular disease
Angina
Arteriosclerosis
Congestive heart failure
Coronary artery disease
Damaged heart valves
Heart attack
Low blood pressure
High blood pressure
Congenital heart defects
Pacemaker
Rheumatic heart disease
Abnormal bleeding
Anemia
Blood transfusion
Hemophilia
AIDS or HIV infection
Arthritis
Autoimmune disease
Rheumatoid arthritis
Systematic lupus erythematosus
Asthma
Bronchitis
Emphysema
Sinus trouble
Tuberculosis
Cancer / Chemotherapy / Radiation treatment
Chest pain upon exertion
Chronic pain
Diabetes type I or type II
Eating disorder
Malnutrition
Gastrointestinal disease
GE Reflux / persistent heartburn
Ulcers
Thyroid problems
Stroke
Glaucoma
Hepatitis, jaundice, or liver disease
Epilepsy
Fainting spells or seizures
Neurological disorders
Gag Reflex Sensitivity
Sleep disorder
Mental health disorders
Recurrent infections
Kidney problems
Night sweats
Osteoporosis
Persistent swollen glands in neck
Severe headaches / migraines
Severe / rapid weight loss
STDs / STIs
Excessive urination
ADD
ADHD
Sensory Processing Disorder
Oral Sensory Sensitivity
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?
Do you have any disease, condition, or problem not listed above that you think we should know about?

Pharmacy Information

Signature

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

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.

Close
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HIPAA Consent Form

General Information

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.

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.

Close
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Patient Screening Form

General Information

Patient Screening

Have you/they recently been vaccinated for COVID-19?
Have you/they recently been tested for COVID-19?
Have you/they tested positive for COVID-19?
Do you/they have fever or have you/they felt hot or feverish recently (14-21 days)?
Are you/they having shortness of breath or other difficulties breathing?
Do you have a cough?
Any other flu-like symptoms, such as gastrointestinal upset, headache or fatigue?
Have you/they experienced recent loss of taste or smell?
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.
Is your/their age over 60?
Do you/they have heart disease, lung disease, kidney disease, diabetes, or any auto-immune disorders?
Have you/they traveled in the past 14 days to any regions affected by COVID-19?
(as relevant to your location)

Signature

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

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.

Close
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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.

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.

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

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.

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.

Close
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.

Close