• HANSWIRTH DENTISTRY

    30 Lake Street
    White Plains, New York 10603
    Phone: 914-946-1500

    Welcome to our Dental Office intake form. We appreciate the confidence you place with us in providing dental services. To assist us in serving you, please complete the following form. The information provided on this form is important for your dental health. By using this HIPAA compliant form, your health information will remain secure and private. If there have been any changes to your health, please tell us. If you have any questions, don’t hesitate to ask. All information is held the strictest confidence.

    This form takes 5 - 7 minutes to complete. Please fill out all required information and check applicable boxes. This form is secured and your personal information will be encrypted on submission. You may skip a question you feel impinges on personal information you do not wish to disclose.

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • DENTAL HEALTH HISTORY

    (must check all boxes Yes or No, to avoid errors)

  • Do you wear dentures?*
  • Does food catch between your teeth?*
  • Do your gums bleed easily? *
  • Do you have difficulty chewing your food? *
  • Are your teeth sensitive?*
  • Do you avoid brushing any part of your mouth because of pain? *
  • Are you apprehensive about dental treatment?*
  • Do you chew on only one side of your mouth? *
  • Do your gums bleed easily?*
  • Do your gums bleed when you floss?*
  • Are your teeth sensitive?*
  • Have you ever noticed slow-healing sores in or about your mouth?*
  • Do your gums feel swollen or tender?*
  • Do you feel twinges of pain when your teeth come in contact with HOT food or liquids?*
  • Do you feel twinges of pain when your teeth come in contact with COLD food or liquids?*
  • Do you feel twinges of pain when your teeth come in contact with sours?*
  • Do your jaws ever feel tired?*
  • Do you feel twinges of pain when your teeth come in contact with sweet?*
  • Do you take fluoride supplements? *
  • Are you dissatisfied with the appearance of your teeth?*
  • Do you prefer to save your teeth? *
  • Do you want to complete dental care?*
  • How often do you brush? *
  • How often do you floss?*
  • Does your jaw make noise so that it bothers you or others? *
  • Do you clench or grid your jaws frequently?*
  • Are you aware of an uncomfortable bite?*
  • Does your jaw get stuck so that you can’t open freely?*
  • Does it hurt when you chew or open wide to take a bite? *
  • Do you have earaches or pain in front of the ears?*
  • Do you have any jaw symptoms or headaches upon awakening in the morning? *
  • Does jaw pain or discomfort affect your appetite, sleep, daily routine, or other activities? *
  • Do you find jaw pain discomfort extremely frustrating or depressing? *
  • Do you take medications or pills for pain or discomfort (pain relievers, muscle relaxants, antidepressants)? *
  • Do you have a temporomandibular (jaw) disorder (TMD)? *
  • Are you a habitual gum chewer or pipe smoker?*
  • Do you have pain in the face, cheeks, jaws, joints, throat, or temples?*
  • Do you gag easily?*
  • Are you unable to open your mouth as far as you want?*
  • Have you had a blow to the jaw (trauma)? *
  • Are you a habitual gum chewer or pipe smoker?*
  • Have you had any problems with previous dental treatment?*

  • MEDICAL HEALTH HISTORY

    Do you have, or have you had, any of the following?

    (must check all boxes Yes or No, to avoid errors)

  • Heart Problems

  • Chest pain*
  • Shortness of breath*
  • Blood pressure problem*
  • Heart murmur*
  • Heart valve problems*
  • Taking heart medication*
  • Rheumatic fever Pacemaker*
  • Artificial health valve*

  • Blood Problems

  • Easy bruising *
  • Frequent nosebleeds *
  • Abnormal bleeding*
  • Blood disease (anemia) *
  • Ever require a blood transfusion*

  • Allergy Problems

  • Hay fever*
  • Sinus problems *
  • Skin rashes*
  • Taking allergy medication*
  • Asthma*

  • Intestinal Problems

  • Ulcers Weight gain or loss*
  • Special diet *
  • Constipation/Diarrhea*
  • Kidney or bladder problems*

  • Bone or Joint Problems

  • Arthritis Back or neck pain*
  • Joint replacement (e.g. total hip, pins, or implants)*
  • Fainting Spells*
  • Seizures or Epilepsy*
  • Stroke(s)*
  • Frequent or severe headaches *
  • Thyroid problems *
  • Persistent cough or swollen glands*
  • Persistent cough or swollen glands*

  • Diabetes

  • Urinate more than 6 times a day*
  • Thirsty or mouth is dry much of the time *
  • Family history of diabetes *
  • Tuberculosis or other respiratory disease*

  • Others

  • Do you drink alcohol*
  • Do you smoke*
  • Hepatitis, jaundice, or liver trouble*
  • Herpes or other STD*
  • HIV-positive/AIDS *
  • Have Glaucoma*
  • Wear contact lenses*
  • History of head injury*
  • Epilepsy or other neurological disease*
  • History of alcohol or drug abuse*
  • Do you have any disease, condition, or problem not listed previously that you feel we should know about*

  • MEDICATION OR PRESCRIPTIONS

    (must check all boxes Yes or No, to avoid errors)

  • Are you allergic, or have you reacted adversely to any of the following?

  • Local anesthetics (“Novocaine”)*
  • Penicillin or other antibiotics*
  • Sulfa drugs*
  • Barbiturates, Sedatives, or sleeping pills*
  • Aspirin, Acetaminophen, or Ibuprofen*
  • Codeine, Demerol, or other narcotics*
  • Reaction to metals*
  • Latex or rubber dam*

  • During the past 12 months, have you taken any of the following?

  • Antibiotics or sulfa drugs*
  • Anticoagulants (e.g., Coumadin)*
  • High blood pressure medicine Tranquilizers Insulin*
  • Orinase, or similar drug, Aspirin*
  • Aspirin, Digitalis or drugs for heart trouble*
  • Nitroglycerin, Cortisone (steroids)*
  • Natural remedies*
  • Nonprescription drug/supplements*

  • Women

  • Women Are you taking contraceptives or other hormones*
  • Are you nursing, *
  • Pregnant*
  • Menopause*

  • Hanswirth Dentistry.

     30 Lake Street, Suite 1F, White Plains, NY 10603 (914) 946-1500

    DEAR PATIENT:

    PAYMENT ARRANGEMENTS ARE REQUESTED AT TIME OF YOUR VISIT

  • Please choose one of the following payment options:*

  • I understand and agree that regardless of my insurance status, I am ultimately responsible for my balance on my account for any professional services rendered. I understand that full payment is due at the time of treatment. Broken appointments will be charged a fee unless the office has received notification 24 hours in advanced.

  • Today's Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • INSTRUCTIONS FOR OUR NOTICE OF PRIVACY PRACTICES

  • PURPOSE: This notice of Privacy Practices presents the information that the HIPPA Privacy Rules require us to give our patients regarding our privacy practices.


    We must provide this Notice to each patient no later than the due date of our first service delivery to the patient, after April 14, 2003. We must also have Notice available at the office for patients to request to take them. We must post the Notice in our office in a clear and prominent location where it is reasonable to expect any patient seeking service from us to be able to read the Notice. Whenever we revise the Notice we must make Notice available upon request on or after the effective date of the revision in a manner consistent with the above instructions. Thereafter, we must distribute the Notice to each new patient at the time of service delivery and to any person requesting a Notice. We must also post the revised notice in our office as discussed above.


    We must make a good faith effort to obtain a written acknowledgment of receipt of this Notice from each individual with whom we have a direct treatment relationship and to whom we provide this Notice, except in emergency situations. If we do not obtain the acknowledgment, we must document our efforts and the reason we did not obtain the acknowledgment. The last page of the notice is a written acknowledgment that each patient should sign. We should keep the acknowledgment in the patient’s medical record.


    NOTICE OF PRIVACY PRACTICES

    THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY, THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

     

    OUR LEGAL DUTIES


    Federal and state law require us to maintain the privacy of your health information. That law also require us to give you notice about our privacy practices, our legal duties, and rights and concerning your health information. We must follow the privacy practices we describe in this notice while it is in effect. This notice takes effect April 14, 2003, and will remain in effect until we replace it. We reserve the right to change in our privacy practices and the new terms of our notice effective for all health information that we maintain, including health information we created or received before we make the changes before we make a significant change in our practices, we will change this notice and make the new notice upon request. You may request a copy of our notice at any time. For more information about our privacy practices or for additional copies of this notice, please contact us using the information listed at the end of this notice.

     

    USES AND DISCLOSURES OF HEALTH INFORMATION


    We use and disclose health information about you for treatment, payment and health care operations. For example:

    TREATMENT: We may use your health information for treatment or disclose it to a dentist, physician or other health care provider, providing treatment to you.

    PAYMENT: We may use and disclose your health information to obtain payment for services we provide to you. We may also disclose your health information to another health care provider or entity that is subject to the federal Privacy Rules for its payment activities.

    HEALTH CARE OPERATIONS: We may use and disclose your health information for our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conduction training programs, accreditation, certification, licensing or credentialing activity. We may disclose your health information to another health care provider or organization that is subject to the federal privacy rules and that has a relationship with you to support some of their health care operations. We may disclose your information to help organizations conduct quality assessment and improvement activities, review the competence or qualification of health care professionals, or detect or prevent health care fraud and abuse.

    ON YOUR AUTHORIZATION: You may give us written authorization to use your health information to a family member, friend or other person to the extent necessary to help with your health care or with payment for your health care. Before we disclose your health information to these people we will provide you with an opportunity to object to our use or disclosure. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We may use our professional judgment and experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescription, medical supplies, x-rays, or other similar forms of health information. We may use or disclose information about you to notify or assist in notifying a person involved in your care, of your location and general condition.

    APPOINTMENT REMINDERS: We may use or disclose your health information to provide you with appointment reminders such (such as voicemail messages, postcard, letters)

    DISASTER RELIEF: We may use or disclose your health information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.

    • As required by law;
    • For public health activities, including disease and vital statistics reporting, child abuse reporting, FDA oversight, and to employers regarding work-related injury;
    • To report adult abuse, neglect, or domestic violence;
    • To health oversight agencies;
    • In response to court and administrative orders and other lawful processes;
    • To law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person;
    • To coroners, medical examiners, and funeral directors;
    • To an organ procurement organization;
    • To avert a serious threat to health safety;
    • In connection with certain research activities;
    • To the military and to federal officials for lawful intelligence, counterintelligence, and national security activities;
    • To correctional institutions regarding inmates; and
    • As authorized by state worker’s compensation laws.

     

    PATIENT RIGHTS


    ACCESS: You have the right to look at or get copies of your health information with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. You may access by sending us a letter to the address at the end of the notice. If you request copies, we will charge reasonable cost-based fee that may include labor, copying costs and postage if you request an alternative format, we will charge a cost-basted fee for providing your health information for a fee. Contact us using the information listed at the end of this notice for most information and fees.

    DISCLOSURE ACCOUNTING: You have the right to receive a list of instances in which we or our business associates disclosed your health information over the last 6 years (but not before April 14, 2003). That list will not include disclosures for treatment, payment, health care operations, as authorized by you, and for certain other activities. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Contact us using the information listed at the end of this notice for more information about fees.

    RESTRICTION: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Any agreement we may make to request for additional restrictions must be in writing signed by a person authorized to make such an agreement on our behalf. Your request is not binding unless our agreement is in writing.

    ALTERNATIVE COMMUNICATION: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. You must make your request in writing. You must specify in your request the alternative means or location, and provide satisfactory explanation how you will handle payment under alternative means or location you request.

    AMENDMENT: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why we should amend the information. We may deny your request under certain circumstances.

     

    QUESTIONS AND COMPLAINTS


    If you want more information about our privacy parties or have questions or concerns, please contact us using the information listed at the end of this notice.

    If you believe that:

    • We may have violated your privacy rights;
    • We made a decision about access to your health information incorrectly;
    • Our response to a request you made to amend or restrict the use or disclosure of your health information was incorrect, or 
    • We should communicate with you by alternative means or at alternative locations.

    You may contact us directly through our website. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

  • SECTION A: THE PATIENTS

  • Format: (000) 000-0000.

  • SECTION B: ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICE NOTICE

  • I * acknowledge that I have received a notice of Privacy Practices from the above-named practice. * . Complete the following if a personal representative signs this authorization on behalf of the patient:

  • SECTION C: GOOD FAITH EFFORT TO OBTAIN ACKNOWLEDGEMENT OF RECEIPT

  • I attest that the above information is correct.
    *

  • Today's Date*
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    2 digit month, 2 digit day, 4 digit year
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