Consent For Release Of Informaton For Treatment, Payment And Health Care Operations Form

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Endodontic Associates of Greater New York
515 Madison Avenue
New York, NY 10022
212-355-4444
Fax: (212) 752-8344
Dr.
Mr.
Mrs.
Ms.
CONSENT FOR
First Name___________________________ Last Name______________________________
RELEASE OF
Birth Date__________________________ Soc. Sec.# ________________________________
INFORMATON FOR
Home Address_____________________________________________ Apt.#______________
TREATMENT,
City______________________________ State_______________ Zip______________
PAYMENT AND
Home Phone__________________________
HEALTH CARE
Cell Phone ______________________________
OPERATIONS
Business Phone________________________ Email__________________________________
Referred By____________________________ Gen Dentist____________________________
THIS FORM IS
Employer-Occupation__________________________________________________________
NECESSARY IN
Bus. Address_________________________________________________________________
ORDER TO COMPLY
Please circle if you have, or have you had any of the following?
WITH THE HEALTH
Heart Murmur
Hepatitis
INSURANCE
Bacterial Endocarditis
Diabetes
APROBABILITY AND
Angina
Glaucoma
ACCOUNTABILITY
Arteriosclerosis
Venereal Disease
ACT OF 1996 (HIPPA)
High Blood Pressure
Asthma
Low Blood Pressure
Urinary Infection
By my signature below, I
Anemia
Kidney Disease
hereby acknowledge
Bleeding Problems
Ulcers
receipt of this notice of
Liver Disease
Cancer
Privacy Practices, and I
Thyroid Disease
Radiation Therapy
acknowledge that the
Lung Disease (T.B.)
Chemotherapy
Practice will use and
disclose my health
1. Are you in good health?
YES
NO
information for purposes
2.Are you presently under the care of a physician?
YES
NO
of treating me, obtaining
If so, what for?_______________________________________________
payment for services
3. Are you presently taking any drugs or medications?
YES
NO
rendered to me, and
If so, please list them__________________________________________
conducting health care
4. Are you taking Fosamax or any bone replacement substitutes?
YES
NO
operations.
5. Do you have heart trouble or cardiovascular disease?
YES
NO
6. Do you have mitral valve prolapse?
YES
NO
I have also been advised
7. Do you have damaged or artificial heart valves?
YES
NO
of my rights to obtain
8. Do you require antibiotic coverage for dental procedures?
YES
NO
access to control my
9. Do you have an artificial hip or other prosthetic device?
YES
NO
Protected Health
10. Do you have a cardiac pacemaker?
YES
NO
Information.
11. Do you experience chest pain upon exertion?
YES
NO
12. Do you routinely take aspirin on a daily basis?
YES
NO
Pregnant? YES NO Nursing? YES NO Birth Control Pills? YES NO
PLEASE CIRCLE ANY OF THE FOLLOWING DRUGS TO WHICH YOU MAY BE ALLERGIC:
Penicillin
Codeine
Erythromycin
Novocaine
____________________
Other Antibiotic
Local Anesthetic
Signature of Patient or of
Aspirin
Adrenaline
Personal Representative,
Ibuprofen (Motrin, Advil)Other Allergies?______________________________________
or Parent/Guardian
Do you have any other problems not mentioned above?
If so, what is it?______________________________________________________
____________________
Name and Address of Physician_________________________________________________
Date
___________________________________________________________________________
Signature_______________________________________________ Date________________

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