Patient Information

    MF
    (required)

    Home PhoneWork PhoneCell PhoneE-MailText Msg

    Health Information

    X Artificial Heart Valves X Artificial Joints X AIDS/HIV X Asthma X Cancer X Diabetes X Diet Controlled Diabetes X Insulin Dependant Diabetes X Anemia X Epilepsy/Seizures

    X Mononucleosis X Fainting/Dizziness X Convulsions X Cardiac Stent X Heart Problems X Heart Murmur X Bladder Problems X Hepatitis X Cerebral Palsy X Measles X Tuberculosis X Mumps X Sinus Problems X Blood Disease X Drug/Alcohol Abuse X Hearing Problems X Kidney Disease

    X Liver Disease X Thyroid Problems X Psychiatric care X Stroke X Ulcers

    X Amoxicillin Allergy X Aspirin Allergy X Codeine Allergy X Dental Anesthetics X Latex Allergy X Penicillin Allergy X Tetracycline Allergy X Sulfa Drug Allergy X Other Drug Allergies

    YesNo

    YesNo
    YesNo
    YesNo

    Dental History

    YesNo
    Well WaterCity WaterBottled Water

    YesNo
    YesNo

    YesNo
    YesNo

    YesNo
    YesNo

    YesNo

    The information that I have given is correct to the best of my knowledge. I understand that it will be held in the strictest of confidence, and it is my responsibility to inform this office of any changes in my child’s medical status. I authorize the dental staff to perform the necessary dental services for my minor/child that may be needed during diagnosis and/or treatment.

    Please sign with mouse or finger:

    Date:

    Person Responsible For Payment

    MaleFemale
    MarriedSingleOther


    Credit Card Authorization (optional)

    MCVisaDiscoverAmEx

           _________________________________

    Insurance Information

    Primary

    YesNo

    SelfSpouseChildOther

    Secondary

    YesNo

    SelfSpouseChildOther

    Consent for Services

    I authorize my insurance company to pay to the dentist or dental group all insurance benefits otherwise payable to me for services rendered. I authorize the use of this signature on all insurance submissions whether manual or electronic.

    I authorize the dentist to release all information necessary to secure payment of benefits.

    A service charge of 1 ½% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 90 days, unless previously written financial arrangements are satisfied.

    It is my responsibility to inform this office of any changes the medical status of my minor/child. I authorize the dental staff to perform any necessary dental services that my minor/child may need during diagnosis and/or treatment.

    I have received a copy of the Notice of Privacy Practices of Michele S. Horton, D.D.S.,FAGD , PC and have been given an option to opt out.

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

    Please sign with mouse or finger:



     

    Drs Horton & Vranas, INFORMATION RELEASE AND AUTHORIZATION FORM

    AUTHORIZATION FOR RELEASE OF INFORMATION

    I authorize the release of information including the entire contents of dental record, including diagnosis, treatment details and financial information.

    This information may be released to:

    Spouse
    Child(ren)
    Other
    Information is not to be released to anyone

    I understand that I have the right to revoke this Authorization, in writing, at any time by notifying this office. Such revocation will not affect actions taken by the requesting person prior to the date he or she received the written revocation. I also understand information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and will no longer be protected by this rule. I understand that my dental provider cannot condition treatment on whether I sign this Authorization.

    This Authorization will remain in effect until terminated by me in writing or until the following date:

    MESSAGES

    Please call:
    my homemy workmy cell

    If unable to reach me:

    You may leave a detailed message
    please leave a message asking me to return call
    Other

    X I agree to two way text messaging with Horton & Vranas DDS until I inform them to STOP.

    It is my responsibility to notify Drs Horton & Vranas of changes and to complete a new form.

     
    Date

    Patient/Authorized Person (Please Print)
     

    Relationship to Patient
     

    AUTHORIZATION FOR TREATMENT OF A MINOR BY DELEGATED PERSONS

    I hereby authorize that the following persons have my permission to seek and authorize dental treatment of the above named minor child in my absence and that his/her protected dental information may be shared.

    Name:
    Relationship to Patient
    Phone Number:

    Name:
    Relationship to Patient
    Phone Number:

    It is my responsibility to notify Drs. Horton & Vranas of changes and to complete a new form.

     
    Date

    Patient/Authorized Person (Please Print)
     

    Relationship to Patient