New Patient Form New Patient Form Today's Date*Preferred Clinic*Preferred clinic selection -BrooklineSouth ShoreName* First Last Address* Street Address City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Email* This email is myHomeWorkSocial Security NumberBirth Date* Home PhoneCell Phone*Please select one:MinorSingleMarriedDivorcedWidowedSpouse's Name First Last Spouse's Cell PhoneGender:*MaleFemaleConfirm my appointment at: Home Work Cell Email Date of last dental visit? Who did you see? Doctor Hygiene Both I don't know Employer:Company*Work PhoneWork Address Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Emergency Contact Information:Contact Name* First Last RelationshipContact Home PhoneContact Work PhoneNearest Relative NOT Living with you:Relative Name First Last Relative RelationshipRelative Home PhoneRelative Work PhoneMEDICAL HISTORY:Physicians Name*Physician PhoneApproximate Date of last exam Are you under medical care now?YesNoHave you been hospitalized for surgical care or serious illness within the last five (5) years?*YesNoAre you taking any medication(s) including vitamins or non-prescription medicine?*YesNoIf yes, please be specific.* Do you use tobacco?*YesNoDo you use controlled substances?*YesNoDo you wear contact lenses on a regular basis?*YesNoDo you use extra pillows to sleep?*YesNoWOMEN ONLY:Are you taking oral contraceptives?*YesNoAre you pregnant could you possibly be pregnant?*YesNoAre you nursing?*YesNoHave you entered menopause?*YesNoDo you take estrogen?*YesNoIf so, what type?*Have you had an adverse allergic reaction to the following? (Check All that apply)Local Anesthetics Yes Sedatives Yes Iodine Yes Sulfa drugs Yes Latex rubber Yes Aspirin Yes Barbiturates Yes Antibiotics (Penicillin, etc.) Yes Metals (nickel, mercury, etc.) Yes Other, please explain in detail Do you have or have you had any of the following:High Blood Pressure Yes Diabetes Yes Low Blood Pressure Yes Stroke Yes Heart Attack/Heart Disease Yes Arthritis Yes Rheumatic Fever Yes Angina Yes Swollen Ankles Yes Cancer Yes Fainting/Seizures Yes Leukemia Yes Asthma/Chronic Bronchitis Yes Anemia Yes Epilepsy/Convulsions Yes Tuberculosis Yes Kidney Disease Yes Glaucoma Yes AIDS or HIV infection Yes Emphysema Yes Thyroid Problems Yes Liver Disease Yes Bone Infection/Disorder Yes Weight Loss Yes Chest Pains/Easily Winded Yes Emotional Disturbances Yes Sinusitis/Sinus Issues Yes Hay Fever/Allergies Yes Radiation Therapy Yes Osteoporosis Yes Frequently Tired Yes Respiratory Trouble Yes Joint Replacement or Implant Yes Hepatitis/Jaundice Yes Sexually Transmitted Diseases Yes Stomach Ulcers Yes DENTAL HISTORYPrevious Dentist's NameDentist's phone numberApproximate date of last exam Are you under dental care elsewhere?YesNoDo you clench or grind your teeth while awake or asleep?*YesNoDo your gums bleed while brushing or flossing?*YesNoHave your parents experienced gum disease or tooth loss?*YesNoAre you satisfied with the appearance of your teeth?*YesNoAre you sensitive to:Sweet or sour liquids or foods?*YesNoHot or cold liquids or foods?*YesNoBiting or chewing?*YesNoDo you:Bite your cheeks or lips regularly?*YesNoHold foreign objects with your teeth?*YesNoFeel pain in any of your teeth?*YesNoHave you noticed any of the following (check all that apply):Have you had any of the following (check all that apply):Clicking in your jaw Yes Orthodontic Treatment Yes Pain (joint, ear, side of face) Yes Periodontal Treatment Yes Pain when opening/closing Yes Oral Surgery Yes Headaches Yes A bite plate or mouthguard Yes Neck or shoulder aches Yes Your teeth ground Yes Difficulty chewing Yes Your bite adjusted Yes Mouth odors or bad tastes Yes Sores or lumps in/near your mouth Yes Tired jaws in the morning Yes Authorization and Release:I certify that I have read and understand the above information to the best of my knowledge. I have answered the above questions accurately, and will not hold Dr. Spitz or any member of his team responsible for any errors or omissions that I may have made in the completion of this form. I understand that I can request assistance at any time to complete this form. I authorize this office to release any information including the diagnosis and the records of any treatment or examination rendered to my child or me during the period of treatment to third party payers and/or health practitioners. I understand and acknowledge that I am financially responsible for the services provided for my dependents and myself, regardless of insurance coverage.Signature of patient or guardianDate Print name of patient or guardianRelationship to patient, if guardianDENTAL INSURANCE INFORMATION:Insured's Name*Insured's Birth Date* Social Security #*Relationship to PatientInsured's Employer*Insurance Company*Group/Policy Number*How did you hear about Dr. Spitz/Smileboston Cosmetic and Implant Dentistry? Please be as specific as possible. Doctor/Patient referrals, Radio, Insurance, Dr. Spitz’s Article(s), Magazine, TV News Report, (If the Internet, what keywords were important? What site did you start with?)Answer to how?* What Radio Station(s) do you prefer during treatment?What Magazine(s)/Newspapers would you like to see in our reception area?Which of the following are factors for you as it relates to your dental treatment? Fear of Treatment Fee for Treatment Time/Scheduling Other (please explain)Would you like an application for financing?YesNoIs there anything additional that we should know that would allow us to make your experience at Smileboston Cosmetic and Implant Dentistry exceptional? General Consent Massachusetts regulations mandate that we inform you of everything we do in the office and obtain your consent for any treatment rendered including a diagnostic exam. This regulation is aligned with our philosophy that an informed patient can make informed choices for their own oral health. In order to conform with the new regulations we will be asking you to sign many forms stating that we have discussed conditions of your teeth and surrounding structures, as well as options for restoring the teeth and surrounding structures. In order for us to treat you appropriately we will need to conduct an examination of your teeth and oral structures. This examination may include, a head and neck exam, intra and extra oral examination, an examination of the teeth, an oral cancer screening, a review of your past medical history, your current medical conditions including all medications you may be taking, photographs of your teeth and smile, x-rays (so that a proper diagnosis can be achieved), evaluation of your bite and the TM Joint, and impressions of your teeth. I authorize and consent to an examination by all doctors and hygienists at Smileboston Cosmetic and Implant Dentistry. This examination may include any or all of the previously mentioned parts of an examination. I consent to the necessity of x-rays during this examination. I understand that the benefits of dental x-rays to properly diagnose my condition outweigh any risk posed by the additive effects of radiation exposure. It has been explained to me that dental x-ray exposure in this office is minimized by the use of digital technologies and that my overall health is the main concern of the doctors treating me. I certify that I have read and understand the above information to the best of my knowledge. My questions have been sufficiently and accurately answered and I will not hold Dr. Spitz or any member of his staff responsible for any errors or omissions that I may have made in the completion of this form. I authorize and consent to the use of certain photographs/x-rays of me taken by Steven D. Spitz, DMD and I hereby grant Dr. Spitz permission to reproduce, publish, print, use, and distribute copies of such photographs/x-rays either in an official medical publication or to promote this office, so long as my identity is not made public. These photographs/x-rays may be in the form of prints, slides, or film for use in connection with articles, lectures, or television broadcasts dealing with jaw or dental disorders. I specifically waive any claim for invasion of my personal privacy, which might accrue to me on account of the use of such pictures without my express consent in each instance. I authorize this office to release any information including the diagnosis and the records of any treatment or examination rendered to me or to my dependent(s) during the period of treatment to third party payers and/or health practitioners. I understand and acknowledge that I am financially responsible for the services provided for me or my dependents, regardless of insurance coverage. I hereby give my consent to all doctors and hygienists of Smileboston to examine diagnose and treat me and/or my dependent(s). Procedures covered include basic restorative (fillings) and preventive procedures. This consent will be in effect until my dependent or I am no longer an active patient of Smileboston. General Consent Form* I have read the General Consent and agree to all statements above. HIPAA - NOTICE OF GROUP INSURANCE COMMISSION PRIVACY PRACTICES Effective September 3, 2013 THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. By law, the GIC must protect the privacy of your personal health information. The GIC retains this type of information because you receive health benefits from the Group Insurance Commission. Under federal law, your health information (known as “protected health information” or “PHI”) includes what health plan you are enrolled in and the type of health plan coverage you have. This notice explains your rights and our legal duties and privacy practices. The GIC will abide by the terms of this notice. Should our information practices materially change, the GIC reserves the right to change the terms of this notice, and must abide by the terms of the notice currently in effect. Any new notice provisions will affect all protected health information we already maintain, as well as protected health information that we may receive in the future. We will mail revised notices to the address you have supplied, and will post the updated notice on our website at www.mass.gov/gic. Required and Permitted Uses and Disclosures We use and disclose protected health information (“PHI”) in a number of ways to carry out our responsibilities. The following describes the types of uses and disclosures of PHI that federal law requires or permits the GIC to make without your authorization: Payment Activities: The GIC may use and share PHI for plan payment activities, such as paying administrative fees for health care, paying health care claims, and determining eligibility for health benefits. Health Care Operations: The GIC may use and share PHI to operate its programs that include evaluating the quality of health care services you receive, arranging for legal and auditing services (including fraud and abuse detection); and performing analyses to reduce health care costs and improve plan performance. To Provide You Information on Health-Related Programs or Products: Such information may include alternative medical treatments or programs or about health-related products and services, subject to limits imposed by law as of September 23, 2013 Other Permitted Uses and Disclosures: The GIC may use and share PHI as follows: to resolve complaints or inquiries made by you or on your behalf (such as appeals); to enable business associates that perform functions on our behalf or provide services if the information is necessary for such functions or services. Our business associates are required, under contract with us, to protect the privacy of your information and are not allowed to use or disclose any information other than as specified in our contract. Our business associates are also directly subject to federal privacy laws; for data breach notification purposes. We may use your contact information to provide legally-required notices of unauthorized acquisition, access or disclosure of your health information; to verify agency and plan performance (such as audits); to communicate with you about your GIC-sponsored benefits (such as your annual benefits statement); for judicial and administrative proceedings (such as in response to a court order); for research studies that meet all privacy requirements; and to tell you about new or changed benefits and services or health care choices. Required Disclosures: The GIC must use and share your PHI when requested by you or someone who has the legal right to make such a request on your behalf (your Personal representative), when requested by the United States Department of Health and Human Services to make sure your privacy is being protected, and when otherwise required by law. Organizations That Assist Us: In connection with payment and health care operations, we may share your PHI with our third party “Business Associates” that perform activities on our behalf, for example, our Indemnity Plan administrator. When these services are contracted, we may disclose your health information to our business associates so that they can perform the job we have asked of them. These business associates will be contractually bound to safeguard the privacy of your PHI and also have direct responsibility to protect your PHI imposed by federal law. Except as described above, the GIC will not use or disclose your PHI without your written authorization. You may give us written authorization to use or disclose your PHI to anyone for any purpose. You may revoke your authorization so long as you do so in writing; however, the GIC will not be able to get back your health information we have already used or shared based on your permission. Your rights You have the right to: Ask to see and get a copy of your PHI that the GIC maintains. You must ask for this in writing. Under certain circumstances, we may deny your request. If the GIC did not create the information you seek, we will refer you to the source (e.g., your health plan administrator). The GIC may charge you to cover certain costs, such as copying and postage. Ask the GIC to amend your PHI if you believe that it is wrong or incomplete and the GIC agrees. You must ask for this by in writing, along with a reason for your request. If the GIC denies your request to amend your PHI, you may file a written statement of disagreement to be included with your information for any future disclosures. Get a listing of those with whom the GIC shares your PHI. You must ask for this in writing. The list will not include health information that was: (1) collected prior to April 14, 2003; (2) given to you or your personal representative; (3) disclosed with your specific permission; (4) disclosed to pay for your health care treatment, payment or operations; or (5) part of a limited data set for research; Ask the GIC to restrict certain uses and disclosures of your PHI to carry out payment and health care operations; and disclosures to family members or friends. You must ask for this in writing. Please note that the GIC will consider the request, but we are not required to agree to it and in certain cases, federal law does not permit a restriction. Ask the GIC to communicate with you using reasonable alternative means or at an alternative address, if contacting you at the address we have on file for you could endanger you. You must tell us in writing that you are in danger, and where to send communications. Receive notification of any breach of your unsecured PHI. Receive a separate paper copy of this notice upon request. (An electronic version of this notice is on our website at www.mass.gov/gic.) If you believe that your privacy rights may have been violated, you have the right to file a complaint with the GIC or the federal government. GIC complaints should be directed to: GIC Privacy Officer, P.O. Box 8747, Boston, MA 02114. Filing a complaint or exercising your rights will not affect your GIC benefits. To file a complaint with the federal government, you may contact the United States Secretary of Health and Human Services. To exercise any of the individual rights described in this notice, or if you need help understanding this notice, please call (617) 727-2310, extension 1 or TTY for the deaf and hard of hearing at (617)-227-8583. HIPAA - NOTICE OF GROUP INSURANCE COMMISSION PRIVACY PRACTICES* I have read the HIPAA - NOTICE OF GROUP INSURANCE COMMISSION PRIVACY PRACTICES above and understand and agree. At Smileboston, we depend on your feedback, both positive and constructive, to excel. We appreciate every comment. Thank you for your time and for experiencing our office.