Mountain Range Dentistry PATIENT INFORMATION PATIENT’S NAME LAST______________________________FIRST______________________________MI_____DATE ___________ GENDER (M) (F)_____AGE___________BIRTHDATE__________________ DRIVER’S LICENSE NUMBER_____________________ ADDRESS______________________________________________CITY__________________________STATE__________ZIP__________ PARENT/GUARDIAN’S NAME (IF MINOR) ____________________________________________________________________________ EMPLOYER ________________________________________________OCCUPATION___________________________________________ REFERRED BY ______________________________________ RESPONSIBLE PARTY (IF DIFFERENT FROM ABOVE) NAME LAST______________________________FIRST______________________________MI_____ ADDRESS______________________________________________CITY__________________________STATE__________ZIP___________ HOME PHONE _________________________WORK PHONE_________________________CELL PHONE__________________________ EMPLOYER ________________________________________________OCCUPATION____________________________________________ RELATIONSHIP TO PATIENT_______________________________________ DENTAL INSURANCE INFORMATION DO YOU HAVE DUAL COVERAGE? Y/N_____ SUBSCRIBER NAME__________________________________________________________ EMPLOYER___________________________ BIRTHDATE___________________ SOCIAL SECURITY #/ID #_________________________ INSURANCE COMPANY ____________________________________GROUP/PLAN NO._______________________________________ SECONDARY SUBSCRIBER NAME__________________________________________________________ EMPLOYER___________________________ BIRTHDATE___________________ SOCIAL SECURITY #/ID #_________________________ INSURANCE COMPANY ____________________________________GROUP/PLAN NO._______________________________________ PHONE NUMBERS AND CONTACTS HOME PHONE _________________________WORK PHONE_________________________CELL PHONE__________________________ BEST NUMBER TO BE CONTACTED:____________________________E-MAIL _______________________________________________ EMERGENCY CONTACT NAME __________________________________________________________RELATIONSHIP _____________________________________ BEST NUMBER TO REACH YOUR CONTACT IN THE EVENT OF AN EMERGENCY________________________________________ Nick Chiovitti D.D.S. Paul Mizoue D.D.S. Ankur Jolly D.D.S. 1005 West 120th Avenue, Suite 800 Westminster, Colorado 80234 303-452-2221 Mountain Range Dentistry DENTAL/HEALTH HISTORY Reason for today’s visit____________________________________________________________________________________________ Former Dentist_________________________ City/State_________________________ Date of last visit___________________ Date of last dental x-rays_____________________ Any PRE-MEDICATION needed?__________________ Place a mark on “yes” or “no” to indicate if you have had any of the following: Bad breath Yes No Bleeding gums Yes No Blisters on lips/mouth Yes No Dry mouth Yes No Fingernail biting Yes No Chew on one side of mouth Yes No Grinding teeth Yes No Swollen gums Yes No Burning sensation on tongue Yes No Yes No Sensitivity to heat Yes No Food collection between teeth Yes No Piercing Yes No Sensitivity to cold Yes No Loose teeth or broken fillings Yes No Sensitivity when bitingYes No Sensitivity to sweets Yes No Sores/growths in your mouth Yes No Jaw pain/clicking Yes No Mouth pain, brushing Yes No Periodontal treatment Yes No Tobacco use Yes No Mouth breathing Yes No Orthodontic treatment Yes No HEALTH HISTORY Have you EVER taken any of the group of OSTEOPOROSIS drugs collectively referred to as “bisphosphonates”? These are used to increase bone density. These include, but are not limited to, oral forms such as Actonel (risedronate), Boniva (ibandronate), Fosamax/ Plus D (alendronate), Skelid (tiludronate), Didronel (etidronate), or I.V. forms such as Aredia (pamidronate), Zometa (zolendronic acid), Bonefos (clodronate).
Place a mark on “yes” or “no” to indicate if you have had any of the following:AIDS/HIV
Women:
Are you taking birth control pills? Yes No
MEDICATIONS, VITAMINS, AND SUPPLEMENTS ALLERGIES
List any medications, vitamins, and supplements you are
Please list any allergies you have especially any drug
currently taking and the correlating diagnosis:
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Nick Chiovitti D.D.S. Paul Mizoue D.D.S. Ankur Jolly D.D.S. 1005 West 120th Avenue, Suite 800 Westminster, Colorado 80234 303-452-2221 Mountain Range Dentistry INFORMED CONSENT
The undersigned hereby authorizes the Doctor to take X-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the Doctorto make a thorough diagnosis of the patient’s dental needs. I authorize Doctor to perform any and all forms of treatment, medication, and therapy thatmay be indicated. I understand that the use of anesthetic agents embodies a certain risk. I understand that my dental insurance is a contract between meand the insurance carrier, and not between the insurance carrier and the Doctor and that I am fully responsible for all dental fees. These fees are due andpayable at the time that services are rendered unless prior financial arrangements have been made. I also agree to assign all insurance benefits to theDoctor for services rendered. Any payments received by the Doctor from my insurance coverage will be credited to my account, or refunded to me if Ihave paid the dental fees incurred. I further understand that a late charge may be applied to my account for any overdue balance. Patient/guardian signature_________________________________________ Dentist signature Nick Chiovitti D.D.S. Paul Mizoue D.D.S. Ankur Jolly D.D.S. 1005 West 120th Avenue, Suite 800 Westminster, Colorado 80234 303-452-2221
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Proyecto de Ley por la que se reconocen y amplían derechos y se establecen medidas en favor de quienes padecieron persecución o violencia durante la Guerra Civil y la Dictadura. (10.10.07) Exposición de motivos El espíritu de reconciliación y concordia, y de respeto al pluralismo y a la defensa pacífica de todas las ideas, que guió la Transición, nos permitió dotarnos de