MICHANOWICZ ENDODONTICS MICHANOWICZ ENDODONTICS, INC. Patient ________________________________________ DENTAL INSURANCE CO._________________________ Subscriber____________________________________ Address _______________________________________ Subscriber’s birth date ____/____/____ ______________________________________________ SSN ____________________________ Employer _____________________________________ Phone # _________________ SSN _______________ Group # __________________ Cell # ___________________ Work________________ SECONDARY INS. CO._____________________________ Subscriber____________________________________ Birth date ___/___/___ Age: ___ Sex: __M __ F Subscriber’s birth date ____/____/____ SSN _________________________________________ Employer _____________________________________ Employer _____________________________________ Emergency Contact Name and Phone # ______________________________________________ Group # __________________
Check: If you have any of these conditions, and need I authorize the release of any dental information necessary antibiotics before dental treatment. to process my claims, and agree to pay any portion of what my insurance does not cover. All arrangements must be ____MITRAL VALVE PROLAPSE made in advance. ____ARTIFICAL VALVE/STENTS ____HIP/KNEE/JOINT REPLACMENT Signature: ________________________Date:_________ Family Dentist Name _________________________Who referred you to our office?_____________________ Are youpregnant? ______ How many weeks/months? _______ Are you taking oral contraceptives? __yes __no
CIRCLE MEDICATIONS THAT YOU ARE ALLERGIC OR SENSITIVE TOO: Penicillin Sulfa Keflex Erythromycin Tetracycline Local Anesthetic Codeine Narcotics Tylenol Aspirin Latex Nitrous Oxide Valium Ibuprofen Foods Other________________________________________ PLEASE LIST All YOUR MEDICATIONS: _______________________________________________ _______________________________________________________________________________________ CHECK IF YOU HAVE OR HAD ANY OF THE FOLLOWING:
__Aids (HIV) __Bruise easily __Glaucoma __Low Blood Pressure __Rheumatic Fever __Allergies/Sinus __Cancer
__Heart Conditions __Lung Disease __Shortness of Breath
__Anemia/Sickle Cell __Chemotherapy/Rad __Heart Murmur __MS
__Stroke
__Arthritis __Cortisone
__Hemophilia __Nervousness __Swelling of feet/hands
__Asthma __Diabetes __Hepatitis __Organ Transplant __Thyroid Disease __Alzheimer’s __Drug Addiction __Herpes
__Other__________ __Tuberculosis
__Blood Disease __Emphysema __High Blood Pressure __Pain in Jaw Joints __Ulcers __Blood Transfusion __Epilepsy/Seizures __Hypoglycemia __Psychiatric Care __Venereal Disease
__Frequent Cough __Kidney Disease __Recent Weight Loss
(TURN OVER) DESCRIPTION OF DENTAL PAIN (Check all that APPLY TODAY) ___Bubble on the gum ___Gums are sore/bleeding ___Tooth feels loose ___ Change in altitude causes pain ___Hot liquids/foods cause pain ___Tooth keeps you awake ___ Cold liquids/foods cause pain ___Pain comes & goes ___Tooth sore to touch or chew ___Constant pain ___Previous root canal ___Throbbing pain ___ Dull ache ___Sharp/shooting pain ____Jaw pain ___Ear pain ___Sweets cause pain ____Symptom Free HIPAA PRIVACY POLICY Persons Involved in Care: We may disclose your health information to a family member, or any person responsible for your care. In the event of an emergency, we will disclose information based on our professional judgment. We will use our judgment and experience to make reasonable inferences of your best interest in allowing a person to pick up prescriptions, medical supplies, x-rays, or other health information. Required by Law: We may disclose information required by law; such to the extent necessary to avert a serious health or safety threat to you or others. We may disclose information to military and federal officials required for intelligence, and other national security activities. Appointment Reminders: We may disclose your health information to provide you with an appointment reminder such as voicemail and letters. Patient Rights: You have the right to get copies of your health information; this request must be in writing. Disclosure Accounting: You have the right to receive a list of instances in which we disclosed your health information. Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of you health information. We do not have to comply. Alternative Communications: You have the right to request that we communicate with you about your health information by alternative means/locations. This request must be in writing. Amendment: You have the right to request that we amend your health information, this request and explanation must be in writing. We may deny the request. We support your privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us/U.S. Department of Health/Services. We are required by law to maintain the privacy of, and provide you with this written notice of our legal duties and privacy practices. Contact Officer: Angel Michanowicz (814) 696-1800 Fax (814) 696-5950 Signature below is only acknowledgement that you received this Notice of our Privacy Practices: PRINT________________________________________________SIGNATURE__________________________________________DATE: ______________
ENDODONTIC CONSENT AND INFORMATION
This is my consent to the endodontic procedures indicated and any other procedures deemed necessary or advisable to the planned endodontic therapy performed by Dr. Michanowicz and any assistants required. I agree to the use of local anesthesia depending on the judgment of the endodontist. I understand the endodontist will consult with me prior to the administration of any sedation. Complications of root canal therapy and anesthesia may include swelling, pain, trismus (restricted jaw opening), exacerbation of temporomandibular joint disorders, infection, sinus involvement, and numbness or tingling of the lip, gum or tongue, which rarely is protracted and even more rarely permanent. I understand that it is my responsibility to report any symptoms to the endodontist immediately. RISKS MORE SPECIFIC TO ENDODONTIC THERAPY: The risks include the possibility of instruments broken within the root canals; perforations (extra openings) of the crown or root of the tooth; damage to bridges, existing fillings, crowns or porcelain veneers, loss of tooth structure in gaining access to canals, and fractured teeth. During treatment complications may be discovered which make treatment impossible, or which may require dental surgery. These complications may include the following: blocked canals due to fillings or prior treatment, natural calcifications, broken instruments, curved roots, periodontal disease (gum disease), splits or fracture of teeth, and perforation of the pulp chamber and root canal system. I UNDERSTAND THAT I AM LEAVING THIS OFFICE WITH A TEMPORARY FILLING, AND THE PERMANENT RESTORATION (FILLING, POST & CORE, CROWN, ONLAY ETC.) WILL BE COMPLETED BY MY GENREAL DENTIST. THE RESTORATION IS NECESSARY FOR THE SUCCESS OF THE ROOT CANAL TREATMENT.
I, the undersigned, certify that the information on both pages are correct and accurate. I understand that root canal therapy is a procedure to attempt to save a tooth which may otherwise require extraction. Root canal therapy has a very high degree of clinical success, results cannot be guaranteed and healing is influenced by many factors. On rare occasions, a tooth which has root canal treatment may require retreatment, surgical correction, or even extraction. Signature of Patient/Parent__________________________ Date________ Dr. Michanowicz_____________________
Curriculum dell’attività scientifica e didattica Federica Fabrizzi Formazione agosto 2010: vincitrice di concorso a Ricercatore a tempo indeterminato nel settore disciplinare IUS 09 (Istituzioni di diritto pubblico) presso la facoltà di giurisprudenza dell’Università Telematica Internazionale Uninettuno; da novembre 2007: dottoranda di ricerca in Teoria dello Stato e
EL CONOCIMIENTO AL SERVICIO DE LA PERSONAALGUNAS VERDADES SOBRE PRINCIPIOS ACTIVOS Descripción General Este documento ha sido elaborado con la finalidad de poder presentar información respecto al mecanismo de acción de las pastil as anticonceptivas. Por supuesto, la prudencia indica que es necesario contrastar esta información con profesionales de la salud, ojalá que sean PROVIDA;