Health History Form

First Name

Last Name

E-mail

Today's Date

Primary Doctor

Doctor's Phone #

Last Exam

Weight

Height

BMI

Any Allergies

Medicines (Include regularly used herbal and non-prescription meds)

Please answer all question to the best of your ability and check off the condition(s) that apply.

Heart Attack

Yes

Chest Pain

Irregular Heart Beat

Palpitation

Heart Surgery

Yes

Catherization

Stents

Bypass

Pacemaker

Heart Valves

Yes

Murmur

Rheumatic Fever

Artificial Valve

Congestive Heart Failure

Yes

Heart Birth Defects

High Blood Pressure

Yes

Hypertension

Asthma

Yes

Emphysema

COPD

Shortness Of Breath with activity

Yes

Liver Disease

Yes

Cirrhosis

Hepatitis

Reflux or GERD

Yes

Ulcers

Kidney Disease

Yes

Dialysis

Kidney Transplant

Stroke

Yes

Mini-stroke

TIA

Vascular Surgery

Diabetes

Yes

Borderline

Diet Or Pill Controlled

Insulin

Thyroid

Yes

Low or High

Goiter

Seizures/Other Neurological Conditions

Yes

Anemia

Yes

Low Blood

Sickle Cell Disease Or Trait

Bleeding Disorder

Yes

Blood Transfusion

Easy Bruising

Weakened or Compromised Immune System

Yes

Cancer

Yes

Cancer Type

Radiation Therapy

Yes

Chemotherapy

Glaucoma

Yes

Eye Surgery

Arthritis (Rheumatoid/Gout)

Yes

Limited Neck Movement

Any Joint Replacement Surgery

Yes

TMJ Problems

Yes

Limited Mouth Opening

Jaw Surgery or Trauma

Chronic Sinus Disease

Yes

Sinus Surgery

Sleep Apnea

Yes

Severe Snoring

Do you use Tobacco products?

Yes

Smoking

Dipping

Chewing

Do you drink Alcohol?

Yes

Current or Past use or abuse of Street/Illegal or Legal Drugs?

Yes

Have you been in a Treatment Program for Alcohol or Drugs?

Yes

Are you Pregnant, Breast Feeding, or Possibly Pregnant?

Yes

Pregnant

Breast Feeding

Possibly Pregnant

Has health changed or were you in the hospital in the last year?

Yes

Have you had previous problems with anesthesia?

Yes

Any medical problems or surgeries not listed?

Yes

Steroid (Prednisone) use for more than two weeks

Yes

Have you ever taken Bone density medication (bisphosphonate), such as: Fosamax, Actonel, Bonivia, Zometa, Aredia, Skelid, Didronel, Prolia?

Yes

I agree the answers given above are honest and accurate as possible.

Patient/Legal Guardian Signature

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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HIPAA Consent Form

General Information

Name

Date of Birth

Street Address

City

State

Zip code

Consent & Notice of Privacy Practices

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operation.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting us by phone or email.

Right to Revoke: You will have the right to revoke this Consent at any time by giving us a written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance of this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

Signature

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my doctor and their staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of their staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

Name of Patient/Legal Guardian

Signature of Patient/Legal Guardian

Date

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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NOTICE OF PRIVACY PRACTICES

11971 Iron Bridge Road
Chester, Virginia 23831

NOTICE OF PRIVACY PRACTICES

THIS NOTICE OF PRIVACY PRACTICES ("NOTICE") DESCRIBES HOW WE MAY USE OR DISCLOSE YOUR HEALTH INFORMATION AND HOW YOU CAN ACCESS YOUR INFORMATION. PLEASE READ IT CAREFULLY.

ABOUT THIS NOTICE

This Notice of Privacy Practices describes how we, our Business Associates, and their subcontractors, may use and disclose your protected health information (PHI) to carry out treatment, payment, or health care operations (TPO), and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information.

"Protected Health Information" includes demographic information, that may identify you and relates to your past, present, or future physical or mental health condition and related health care services including dental care.

This Notice takes effect 5/25/2022. We reserve the right make updates. Updated Notices will be available in our office as well as on our website.

USES AND DISCLOSURES OF PROTECTED HEALTH INFORMATION

Your protected health information may be used and disclosed by our office and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of our practice, and any other use required by law.

Treatment

We will use and disclose your protected health information to provide, coordinate, or manage your care and any related services. This includes the coordination or management of your health care with a third party. For example, your PHI may be provided to another provider to whom you have been referred so they have the necessary information to treat you.

Payment

Your protected health information will be used, as needed, to obtain payment for your services. For example, filing for insurance benefits as applicable for our practice.

Healthcare Operations

We may use or disclose your protected health information as needed, in order to support the business activities of our practice. These activities include, but are not limited to, quality assessment, employee review, training of interns, licensing, billing services, and other business activities.

YOUR RIGHTS

Right to Inspect and Copy: You have the right to inspect and copy your protected health information (fees may apply).
Right to Request Restrictions: You have the right to request a restriction of your protected health information.
Right to Confidential Communications: You have the right to request confidential communications from us by alternative means.
Right to Amend: You have the right to request an amendment to your protected health information.
Right to an Accounting: You have the right to receive an accounting of certain disclosures.
Right to Paper Copy: You have the right to obtain a paper copy of this notice from us.

COMPLAINTS

If you believe your privacy rights have been violated, you may file a complaint with us or with the Secretary of Health and Human Services. You will not be penalized for filing a complaint.

Contact Information:

Chester Oral Surgery
11971 Iron Bridge Road
Chester, Virginia 23831
804-748-6350

U.S. Department of Health & Human Services
Office of Civil Rights
200 Independence Avenue, SW
Room 515 F HHH Building
Washington, DC 20201
www.hhs.gov/ocr

Patient/Legal Guardian Signature

All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.

Submit

Thank You!

We appreciate you taking the time to complete this form. We'll review the information submitted and be in touch with you if anything additional is required.

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