Microsoft word - h&p2.doc

DATE _______________
PATIENT NAME ______________________________ BIRTHDATE _________
RESIDENCE ADDRESS ______________________________________________
CITY _____________________ STATE _____________ ZIP _____________
RESIDENCE PHONE ( ) ____ - ______
EMPLOYER _________________________________ OCCUPATION __________
EMPLOYER ADDRESS _______________________________________________
CITY _____________________ STATE ______________ ZIP _____________
WORK PHONE ( ) ____ - ______
SOCIAL SECURITY # ______ - ____ - ________
SPOUSE'S FULL NAME______________________________________________
(Parent's Name if Child)
EMPLOYER _________________________________ OCCUPATION __________
EMPLOYER ADDRESS _______________________________________________
CITY _____________________ STATE _____________

ZIP ________________
WORK PHONE ( ) ____ - ______
SOCIAL SECURITY # ______ - ____ - ________
WHO IS RESPONSIBLE FOR THIS ACCOUNT? ______________________________
DENTAL INSURANCE COMPANY _________________________________________
POLICY NUMBER _____________________________________________________
PHONE ( ) ____ - ______
BIRTHDATE OF POLICY HOLDER___________________________
NAME ______________________________________________
HOME PHONE ( ) ____ - _______
WORK PHONE ( ) ____ - _______

WHOM MAY WE THANK FOR REFERRING YOU?_____________________________
Please read and sign privacy statement below: I, _____________________________________hereby acknowledge that I have received a copy of this practice’s Notice of Privacy Practices. I have been given the opportunity to ask any questions I may have regarding this Notice. Date:_____________________________ Signature:________________________________________________ Physician's Name ____________________________ Date_______________ Date of last physical _______________________ Have you ever had any of the following (Check all those that apply): ____ Bronchitis/Asthma
____ Kidney Disease
____ Shortness of Breath
____ Diabetes
____ Tuberculosis
____ Thyroid Problems
____ Heart Problems
____ Drug Allergies
____ High Blood Pressure
____ General Allergies
____ Low Blood Pressure
____ Intestinal Disorders
____ Heart Murmur
____ Arthritis
____ Heart Defect from Birth
____ Psychiatric Care
____ Chest Pains
____ Immunosuppressive Disorders
____ Artificial Heart Valves
____ HIV Disease(AIDS,ARC,etc)
____ Heart Attack/Stroke
____ Sexually Transmitted Disease
____ Rheumatic Fever/Rheumatic Heart
____ Chemical Dependency
____ Radiation Treatment
____ Seizures/Convulsions
____ Glaucoma
____ Hepatitis, Jaundice or
____ Steroid Treatment
Liver Disease
____ Cancer
____ Blood Transfusion
____ Bleeding Disorder
**Have you been on any diet/weight loss medications?______

**Do you require antibiotics due to heart problems, joint replacement, etc. prior
to dental procedures? ____

Do you have any drug allergies or have you had any adverse reaction to any medication? ________ If so, what? _______________________________ Have you ever responded adversely to medical/dental treatment? _____
Are you under the care of a physician? _____ For what condition(s):
Are you taking any medications (Prescriptions/Over-the-Counter/Herbal
(NOTE: Antibiotics may render birth control pills ineffective) (Bisphosphonates
(Fosamax, Actonel, Didronel) may cause osteonecrosis of the jaws.)
Please list:

Last hospital admission (date) _____________
(Women) Do you suspect that you are pregnant? _________ Are you nursing? _________
Is there anything else we should know about your medical history?
The above information is accurate and complete to the best of my knowledge and is only for use in my treatment,
billing and processing of insurance for benefits for which I am entitled. I will not hold my oral surgeon or any
member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
I authorize the release of dental and/or medical information to Dr. Sherman from my dentist/physician(s).
Date __________________ Signature_____________________________________
Pamela H. Sherman, D.M.D.
We feel that everyone benefits when there is a definite and clear financial agreement prior to treatment. An estimate of your total fee will be given at your consultation. To make your financial arrangements as easy as possible, we have the following methods of payment. Please check the plan that you would like to use during your treatment here. _____ Plan 1: Payment Upon Service (Amounts
A 5% courtesy discount is offered if the entire fee is paid on the day of treatment. We will assist you in filing your insurance so that you can be reimbursed _____ Plan 2: Divided Payment (Amounts over $250.00 only)
2/3 of total treatment fee is due on the day of treatment. 1/3 is due within 30 days. _____ Plan 3: Health Plans (H.M.O.'s) Patients who belong to HMO’s
(e.g. Healthplus,Consumer Dental, etc.) are the beneficiary of a special fee schedule, negotiated for you by your dental plan. It is not an insurance policy. In order for us to offer you service based on your special fee arrangement, your fee must be paid in full at the time of service. The receptionist will quote you the exact fee prior to treatment. _____ Plan 4: Insurance. (Will be submitted for fees over $250.00)
30% of the total treatment fee is due the day of treatment.
Our office will submit your insurance forms for you.
Please Note:
Your agreement with the insurance company is between you and
your insurance company. If the insurance company does not remit
payment within 60 days after forms have been submitted, the
remaining balance will be required from you.
If there are any
overpayments (taking your 30% down payment into consideration),
you will be promptly reimbursed once payment is received from
the insurance company.
Note: All late payment charges, collection charges and bank charges associated with checks returned due to
insufficient funds or closed accounts are your responsibility. I do ask for 24 hours notice for
Surgical appointments cancelled after 5:00 PM on the business day prior to your appointment are subject
to a $50.00 charge. Thank you.
I hereby certify that I have fully read the above and agree with all terms and
Signature ____________________________________ Date ___________________
Thank you for your cooperation,
Pamela H. Sherman, D.M.D


Microsoft word - exam_key.doc

Name:_ I AM THE KEY_ ___________________ ANTHSCI 178A/278A - Past and Present Pestilence In-class Exam (30 Minutes) 1. Name the three disease designations by origin of transmission (2 pts each – name and definition) (HINT: Hubalek article) 1. Zoonotic – Animal to human transmission (also acceptable in the –osis form) 2. Anthroponotic – human to human transmission 3. Sapronotic


Update on the Prevention and Treatment of Sexually Transmitted Diseases KARL E. MILLER, M.D., DAVID E. RUIZ, M.D., and J. CHRISTOPHER GRAVES, M.D. University of Tennessee College of Medicine, Chattanooga, Tennessee The Centers for Disease Control and Prevention (CDC) recently published updated guide- lines that provide new strategies for the prevention and treatment of sexually transmit- ted

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