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___________________________ IN CASE OF EMERGENCY WHO SHOULD BE NOTIFIED? NAME ______________________________________________ HOME PHONE ( ) ____ - _______ WORK PHONE ( ) ____ - _______ WHOM MAY WE THANK FOR REFERRING YOU?_____________________________ PLEASE COMPLETE MEDICAL HISTORY ON REVERSE
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 supplements)? (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. A WORD ABOUT OUR CREDIT POLICY
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 cancellations. 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 conditions. Signature ____________________________________ Date ___________________ Thank you for your cooperation, Pamela H. Sherman, D.M.D
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