Adrian Pulkrabek, D.D.S. Family and Cosmetic Dentistry 18205 T

Document Sample
Adrian Pulkrabek, D.D.S. Family and Cosmetic Dentistry 18205 T Powered By Docstoc
					Adrian Pulkrabek, D.D.S.
Family and Cosmetic Dentistry
18205 T. 51 st Ave., Ste. 137
Glendale, AZ 85308
(602) 866-9825

    Thank you for choosing Dr. Pulkrabek's office! We are pleased to welcome you and
your family to our office! We offer state of the art technology as well as the most up to
date dental techniques along with a friendly and courteous staff. We hope that your visits
to us are comfortable and meet all of your needs. If there is ever anything we can do to
make your experience with us more comfortable, please do not hesitate to ask. We try to
make every attempt to accommodate your schedule and as such we are open for
appointments Monday-Friday from 8:00 am to 5:00pm. Please take a moment to read the
items below.

    1. We do accept PPO's that insurance carriers provide and our staff will take care of
       filling out the proper insurance forms as well as file them for you. We cannot
       guarantee payment of th~ services rendered and as such the balance not paid by
       the insurance company becomes the patient's responsibility. We do not accept
       any HMO's.

    2. We have a 48-hour (business hours) cancellation policy whereby any appointment
       cancelled with less than a 48 business-hour notice will be subject to a cancellation
       fee of $50.00.

    3. We accept many forms of payment including: Visa, Mastercard, Discover,
       American Express, Care Credit and the Dental Fee Plan as well as cash, checks
       and money orders. Payment is expected as services are rendered unless prior
       financial arrangements have been made.

    4. Please note that any unpaid balance is the patient's responsibility. Should an
       account be left unpaid for a period over 90 days you may be subjected to interest
       and/or a collection fee. Seriously delinquent accounts may be turned over to a
       collection agency.

Again, welcome to our practice! We look forward to serving your dental needs!

 I hereby authorize the doctor to perform any and all forms of treatment, medication and
 therapy that may be indicated in connection with the dental care of the patient above and
 further authorize and consent to the doctor choosing and employing such assistance as he
 deems fit. I also understand that prior to treatment a full explanation of the procedure (s)
.involved will be given by the doctor and or his staff. I agree to pay for all services
 rendered by this office. I also consent to the use of periodic appointment reminder phone
 calls and appointment reminder items sent via mail. I also understand that should my
 account become delinquent, my information may be released to a third party collection
 agency to assist with collecting fees associated with treatment rendered in this office.

Patient Name:

Sizned:                                                Date:
             FanUly and Cos.netic: Dentisb-y
               Adrian E. Pullaabek, D.D.S.
                 18502 N. 51st Ave., #137
                   Glendale, AZ85308
                          (602) 866·9825




We certainly understand that occasionally circumstances arise
that prevent patients from keeping their scheduled appointments.
In the future, if you find it impossible to keep your scheduled
dental appointment please be considerate to give our office a 48
business hour notice in advance.

With that prior notice, we can reschedule your appointment and
allow another patient to have the appointment time originally
reserved for you.

Because our office gives our patients the courtesy of phone
confirmation in advance, failure to keep your scheduled
appointments without a 48 business hour notice will result in a
$50.00 fee posted to your account.

Thank you in advance for your cooperation. Having
understanding patients enables us to better serve the needs of all
our patients.

Sign:                                                 _

Date:
        -------------------------------------
Sincerely,

Dr. Pulkrabek and Staff
                                                                 AdriIm PuIJaabek, D.D.s_
                                                                 .Anowbead Office Plaza
                                                                1820SN_ 51- Ave.. Stc. 137
                                                                   GIe!wIaIe, A2 lS30lI

                                  CONSENT FOR USE AND DISCLOSURE OF HEALTH JNFORMATION

SECTION A:. PATIENT GIVING CONSENT

NAME:
ADDRESs-

TELEPHONE:                                                                       EMAIL-

PATIENT       NUMBER-                                                            SSN-

SECTION B: 10 THE PATIENT- PLEASE READ THE FOLLWING STAlEMENTS                                         CAREFULL Y_

~         of Comcm: By sigains this fi:mn, you will conseat to our use and disclosure                of)OW"   prouc;ted health infunnalion to deny out
treIbDI!:IIl.paymem activities. IIld bcIlthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Policy Procedures before you decide w:heIher to sign this
Conscm. Our Notice provides a description of our tn:IIImCnl, paymc:ot solicitJbla, sod ~             opmttions, of the uses and
disclosures we may make of your protected health infomuItion, and of oma imponant JmI!aS about your prerccICd bcaIth
information. A copy of our Notice accompanies this Coosem. We ~                you to read it carefully and compJerely before signing
this Consent

We reserve tbc right to cbaDge our privacy practices as described in our Notice ofPrMlcy Practices_ If we change our privacy
practices. we will issue a revised Notice of Privacy Praaia:s, which win axttain tbc c:banFs- Those changes InBY apply to any of
your protcc:tcd health information that we maintain.

You InBY obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting;

Contact Person:      Office Manager
Telepbooe: (602) 866-9825        Fax: (602) 866-2404-
Address: 18205N. 51- Ave.,#I37
                     Glendale:, AZ 85308

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

SIGNATURE:

            I,                                          ' have had full opportunity to read/and consider the contents afthis Consent
form and your Notice of Privacy Practices. I undc:rsWld that, by signing this Consent foem, I am giving my consent to your use and
disclosure of my protected health infonnarion to carry out trCIIIment, payment activities and health ClR operations.

Sjgncure-                                                                                    Date:

If this Consent   js   signed   by a   personal reoresc:ntative on beha!fofthe    patient,   oomoJem the following:
Pmonal      Representative's     Name'

Rcllllionsbituo Patient:

                                YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.
                                             Include completed Consent in the patient's chart.




                                                                                                                      '.
                            IDP AA Privacy Practices
PATIENT PROTECTIONS

The new privacy regulations ensure a national floor of privacy protections for patients by limiting the ways
that health plans, pharmacies, hospitals and other covered entities can use patients' personal medical
information. The regulations protect medical records and other individually identifiable health information,
whether it is on paper, in computers or communicated orally. Key provisions of these new standards
include:

    •    Access To Medics) Records. Patients generally should be able to see and obtain copies of their
         medical records and request corrections if they identify errors and mistakes. Health plans, doctors,
         hospitals, clinics, nursing homes and other covered entities generally should provide access these
         records within 30 days and may charge patients for the cost of copying and sending the records.

    •    Notice of Privacy Practices. Covered health plans, doctors and other health care providers must
         provide a notice to their patients how they may use personal medical information and their rights
         under the new privacy regulation. Doctors, hospitals and other direct-care providers generally will
         provide the notice on the patient's first visit following the April 14, 2003, compliance date and
         upon request. Patients generally will be asked to sign, initial or otherwise acknowledge that they
         received this notice. Health plans generally must mail the notice to their enrollees by April 14 and
         again if the notice changes significantly. Patients also may ask covered entities to restrict the use
         or disclosure of their information beyond the practices included in the notice, but the covered
         entities would not have to agree to the changes.

    •    Limits on Use of Personal Medical Information. The privacy rule sets limits on how health
         plans and covered providers may use individually identifiable health information. To promote the
         best quality care for patients, the rule does not restrict the ability of doctors, nurses and other
         providers to share information needed to treat their patients. In other situations, though, personal
         health information generally may not be used for purposes not related to health care, and covered
         entities may use or share only the minimum amount of protected information needed for a
         particular purpose. In addition, patients would have to sign a specific authorization before a
         covered entity could release their medical information to a life insurer, a bank, a marketing firm or
         another outside business for purposes not related to their health care.

    •    Prohibition on Marketing. The final privacy rule sets new restrictions and limits on the use of
         patient information for marketing purposes. Pharmacies, health plans and other covered entities
         must first obtain an individual'S specific authorization before disclosing their patient information
         for marketing. At the same time, the rule permits doctors and other covered entities to
         communicate freely with patients about treatment options and other health-related information,
         including disease-management programs.

    •    Stronger State Laws. The new federal privacy standards do not affect state laws that provide
         additional privacy protections for patients. The confidentiality protections are cumulative; the
         privacy rule will set a national "floor" of privacy standards that protect all Americans, and any
         state law providing additional protections would continue to apply. When a state law requires a
         certain disclosure -- such as reporting an infectious disease outbreak to the public health
         authorities -- the federal privacy regulations would not preempt the state law.

    •   Confidential communications. Under the privacy rule, patients can request that their doctors,
        health plans and other covered entities take reasonable steps to ensure that their communications
        with the patient are confidential. For example, a patient could ask a doctor to call his or her office
        rather than home, and the doctor's office should comply with that request if it can be reasonably
        accommodated.
    •    Com plaints. Consumers may file a formal complaint regarding the privacy practices of a covered
         health plan or provider. Such complaints can be made directly to the covered provider or health
         plan or to HHS' Office for Civil Rights (OCR), which is charged with investigating complaints
         and enforcing the privacy regulation. Information about filing complaints should be included in
         each covered entity's notice of privacy practices. Consumers can find out more information about
         filing a complaint at http://www.hhs.gov/ocr/hipaa   or by calling (866) 627-7748.

HEALTH PLANS AND PROVIDERS

The privacy rule requires health plans, pharmacies, doctors and other covered entities to establish policies
and procedures to protect the confidentiality of protected health information about their patients. These
requirements are flexible and scalable to allow different covered entities to implement them as appropriate
for their businesses or practices. Covered entities must provide all the protections for patients cited above,
such as providing a notice of their privacy practices and limiting the use and disclosure of information as
required under the rule. In addition, covered entities must take some additional steps to protect patient
privacy:

    •    Written Privacy Procedures. The rule requires covered entities to have written privacy
         procedures, including a description of staff that has access to protected information, how it will be
         used and when it may be disclosed. Covered entities generally must take steps to ensure that any
         business associates who have access to protected information agree to the same limitations on the
         use and disclosure of that information.

    •    Employee Training and Privacy Officer. Covered entities must train their employees in their
         privacy procedures and must designate an individual to be responsible for ensuring the procedures
         are followed. If covered entities learn an employee failed to follow these procedures, they must
         take appropriate disciplinary action.

    •    Public Responsibilities. In limited circumstances, the final rule permits -- but does not require --
         covered entities to continue certain existing disclosures of health information for specific public
         responsibilities. These permitted disclosures include: emergency circumstances; identification of
         the body of a deceased person, or the cause of death; public health needs; research that involves
         limited data or has been independently approved by an Institutional Review Board or privacy
         board; oversight of the health care system; judicial and administrative proceedings; limited law
         enforcement activities; and activities related to national defense and security. The privacy rule
         generally establishes new safeguards and limits on these disclosures. Where no other law requires
         disclosures in these situations, covered entities may continue to use their professional judgment to
         decide whether to make such disclosures based on their own policies and ethical principles.

    •    Equivalent Requirements For Government. The provisions of the final rule generally apply
         equally to private sector and public sector covered entities. For example, private hospitals and
         government-run hospitals covered by the rule have to comply with the full range of requirements.
                                                                                      PATIENT REGISTRATION
              ID:               _            Chart ID:                                      _

First Name:                                                                          _     Last Name:                                                                                Middle Initial:

Patient Is:         0    Policy Holder                                               Preferred Name:                                                                         _

                    o    Responsible     Party
~Respon~ble           Party 0fsomeone        other than the patienQ-----------------------                                                                         ----------~

    First Name:                                                                             Last Name:                                                                           _   Middle Initial:

    Address:                                                                                           Address 2:                                                                                      _

    City, State, Zip: __________________________________                                                                                            Pager:                                                     _

    Home Phone:                                        _    Work Phone:                                             Ext:                         Cellular:                                                 _

    Birth Date:                                                    SocSec:                                         _             Drivers Lic:
                                                                                                                                                 ----------
      o Responsible         Party is also a Policy Holder for Patient
                                                            ---+--
                                                                                     0 Primary     Insurance Policy Holder
                                                                                                      -------------- ----.--
                                                                                                                                         0 Secondary
                                                                                                                                                    ..
                                                                                                                                                  .-_
                                                                                                                                                         Insurance Policy Holder
                                                                                                                                                     _-------------_._.------
            I
      Patientnformation




i   Address:

    City:

    Home Phone:

    Sex:            0 Male                o      Female
                                                            Work Phone:
                                                                                 State I Zip:




                                                                                Marital Status:
                                                                                                       Address 2:




                                                                                                   0 Married
                                                                                                                   Ext:

                                                                                                                       o    Single        o
                                                                                                                                              Pager:

                                                                                                                                                Cellular:

                                                                                                                                                 Divorced        0 Separated 0 Widowed
                                                                                                                                                                                                       _

                                                                                                                                                                                                           _




    Birth Date:                                            Age:              _       Soc. Sec:                                               Drivers Lic:
                                                                                                                                                             -----------
    E-mail:                                                                                 _      o   I would like to receive correspondences               via e-mail.

                     Section 2                                                                                                                    Section 3

    Employment        Status:       0   Full Time         o Part Time              o     Retired
                                                                                                                                                            Referred By:

                                                                                                                                                    Previous Dentist:
                                                                                                                                                                                                           _

                                                                                                                                                                           ---------
    Student Status:         0 Full Time                   o Part Time                                                                           Emergency       Contact:
                                                                                                                                                                           --------
    Medicaid ID:                    _                             Pref. Dentist:                                       _                     Emergency        Contact #:
                                                                                                                                                                           --------

    Employer ID:                                                  Pref. Pharmacy·


    Carrier ID:                                                   Pref. Hyg.:


iPrim"y         insurance lnformation
    Name of Insured:                                                                                         Relationship      to InsuredO       Self        o    Spouse     0 Child          o   Other

I   Insured Soc. Sec:                                                            Insured Birth Date:

I Employer:                                                                                                Ins. Company:


I             Address:                                                                                             Address:


            Address 2:                                                                                           Address 2:

      City,State,Zip:                                                                                        City.State.Zip:

    Rem. Benefits:                               .00      Rem. Deduct:                               .00

rseCOndary          Insurance Information

    Name of Insured:                                                                                         Relationship      to InsuredO       Self        o    Spouse     0 Child          o   Other

    Insured Soc. Sec:                                                            Insured Birth Date:

    Employer:                                                                                              Ins. Company:

              Address:                                                                                             Address:


            Address 2:                                                                                          Address 2:


      CitY,State,Zip:                                                                                       CitY,State,Zip:

    Rem. Benefits:                               .00      Rem. Deduct:                              .00
P If T'S D                             Al HISTORY
PATIE        T'S      AM[                                                                                                                     D TE OF BIRTH

 REA 0             FOl~ THI~           1~11

\\HE          \\A~ YOll~       l"SI             IH            T I \I~1f                                                  WHAT \\AS DO                 r   THE

 110\\ OnE             DID VOL                  1'>11THE Of"-ill<;T SHaRF HH

 PIUVIOllS DE TlST (,,\1E                                          0 LO( ATIO      )__

 H       E VOL HAD A (0                        H
                                            1PLE ~[fm ~ Of DE T l fiLMS ( -I~ YS) T K[                                WHf             HWI

 HO          or n      00      0        BR' ~II YOL R IEUH                                   _                  HO       OFT[         DO VOL flOSS                   YOll~ THTH

 I~    rot    R 01~1 KI C,              ATEI~ f tu                   RloATE D


                                                                                             YES      o                                                                                                               YES            o
 DO YOLR GUMS At I [D WHILE BRUSH I (,                                                                      r0        YOU BIT[ YOLl~ UPS                       on    (HFE I\~ f1~rQUF                       IL)"
     OR fI O'iSI        C .                                                                                 HA [ YOU NOTIUD                       A 'y LOOSE                 I (, Of
     IU '10ll~ H ETH Sf                 Sill L TO HOI OR (OLD                                                   YOLR TfETH               .
      LlQLlOS       FOOD                                                                                    DOE S FOOD IE                     D TO m (0 t[ (                     l (,HT
     RE 'OL!{         IEHH 'i[          <;11
                                           IH                 TO S E£ T OR 0             R                      BETWH            )0          R TEF-TH ..
     LlQLlDS        FOODS                                                                                   H         E )OL      EYf R HAD PfRlODO                         T l
 00 VOL FEEL P I                       TO                      )     Oll~ TfETH                                 IRf      T\iE    T «,U          <;).
 I 0 VOL H VL                 ) 50lU SOL L iPS I                                  OR                        [       fR     OR      A BITf Pl 11 0                        OTHER            PPII             CF
       F I~)"O R \10L HI                                                                                    H         [YOl       EVER H D A ) OIFFI( III                              f        m       TlO S
 HAVEVOL HAD"                      Y HI AD,                        [( K OR JA\\ IMLRIES                         I     THI PAST.                                     ..
 H       E YO        l: U{ E       pum                    UD              OF HI[                            HWE VOl              [VfR        HAD A ) PI~OLO                      (.1 D BLH DI                   c.
 f     I LO    I c. PlmBU M<; I                               YOlJl~ JA ~                                       fOllOWI           (J     E WAC TlO C;
      (lIC    KI (,                                                                                         DO YOL \\ f               I? or      TlIU S OR P ImAl C;
      P I     (101 T [        I~ SIDl 01 I (f)                                                                  If    ns,       DAn      OF PL U               1E I
      DlrFlCUlTYI             OPf           I (,01~(l0<;1                  ( •.                             H vr VOl f ER REefl                               ED OR l H'tCI[                    E
      DIFFIC t.:LJ) I         (HE           I    (J                                                             I    sreucuo 5                In(,Alml           G THE (              Rf Of
 O( VOL HA ( FRIQUE                             1 HE OA( HES                                                    'tOURTffTH                    D (Jl       15
 DO VOL cu               (H    OR (.I~I 0 YOUI~ Iff TH


1/ YOl (OLID                (HA        GE                 YrHI~G BOLT                        YOL CH
                                                                     YO I~ S,\1I11: WH T WOULD                                           (,U




                                                                                                           I SlR      (I (O\1P        10 P' UIIU( Il' 10 IHf I
                                                                                                           I '>1        I AI HII., OlHIR~N      P Y~BII 10 M
                                                                                                           or 11\1 Ir'I; UR\ CI ( RRllR ~ ••. P) u s IH          IHI                                        A(   n     ~l   All    f( R
                                                                                                           SI R ICI 5 I AGRII                       SIBl
                                                                                                                                   10 BI Rf SI'() •••• [ 'OR PAYMI ""                                       01       I\ll   Sf R\ I I.,
                                                                                                           RI    I RI D 0'" ~Y HI H\lf Ol~ n Dll'l     nr I'>
                                                                                                           x             ____                                                                        DTI
                                                                                                            Ie.. AIURE or        P\1Il       T OR PARl         1 (.li RDIA       /I       II   or~

[)()( lORS COM\1~ IS



     _=-_-_--------5IG                                                          'ATURl.:===::::-:=--=_--::--=-:::-:-::================:-                                              _------
                                                                                                                                                                            DA_T_E=--=--_-


                                                                                                                                                                                               PATIENT'S NUMBER
                                   -                 ••   ,                 1                                                                             •                                                                               '




                                                                                         HEALTH HISTORY
                                                      /\
PATIENT'S MEDICAL HISTORY
PATIENT'S NAME                                                                                                   DATE OF BIRTH                                                                    _

ALTHOUGH DENTAL PERSONNEl PRIMARILY TREAT THE AI~EA IN AND AROUND YOUR MOUTH, YOUR MOUTH IS A PART OF YOUR
ENTIRE BODY. HEALTH PI~OBLEMS THAT YOU MAY HAVE, OR MEDICATION THAT YOU MAY BE TAKING, COULD HAVE AN IMPORTANT
INTERRELATIONSHIP  WITH TH[ DENTISTRY THAT YOU WILL BE RECEIVING. THANK YOU FOR ANSWERING THE FOLLOWING
QUESTIONS.
                                                                             YES   NO                                                                                      YES       NO
 1. ARE YOU IN GOOD HEALTH            , , . . . ..                            0     C     12. HAVE YOU EVEI~ TAKEN FEN,PHEN/I~EDUX . ' ..              I'
 2. HAVE THERE BEEN ANY CHANGES IN YOUR                                                   1 }. HAVE YOU EVEI~ TAKEN FOSAMAX, BONIVA,
    GENERAL HEALTH WITHIN THE PAST YEAR, . "                                  0                ACTONEL OR ANY CANCER MEDICATIONS
 }. DATE OF YOUR LAST PHYSICAL EXAM:                                               _           CONTAINING BISPHOSPHONATES? , , ... , , "               LJ                                u
 4. PHYSICIAN'S NAME                                                                _     14. HAVE YOU TAKEN VIAGRA, REVATlO, CIALIS OR
    ADDRESS                                                                         _
    PHONE NO.                                                                       _
                                                                                               LAVITRA IN THE LAST 24 HOUI~S? .. , , . . . . ..                            n             n
                                                                                          15. DO YOU USE TOBACCO ,                      , , . . . . .. 0                                 [J
  5. ARE YOU NOW UNDER THE CAI~E OF A                                                     16, DO YOU OR HAVE YOU USED CONTlWLLED
         PHYSICIAN .. ' , , ....   , , , , , . , , . , , , , , , ....         0     u          SUBSTANCES .. , .....  , . . . . . . . . . . . . . . ..                     n             0
 6. HAVE YOU EVER BEEN HOSPITALIZED FOR
                                                                                          17, ARE YOU WEARING CONTACT LENSES. . . . . ..               0                                 0
        ANY SURGICAL OPERATION OR SERIOUS ILLNESS
        PLEASE EXPLAIN.                                                             _     18. DO YOU HAVE A PERSISTENT COUGH OR THROAT
                                                                                               CLEARING NOT ASSOCIATED WITH A KNOWN
 7. ARE YOU TAKING ANY MEDICINE(S)                                                             ILLNESS (LASTING MORE THAN } WEEKS) .. ,.               ~_                                U
         INCLUDING NON,PRESCI~IPTION MEDICINE,                          ,.    [l    o     19. DO YOU HAVE ANY DISEASE, CONDIlION                on


 8.
         IF YES, WHAT MEDICINE(S) ARE YOU TAKING

        HAVE YOU HAD ANY ABNORMAL BLEEDING.                                   0
                                                                                    _

                                                                                    c
                                                                                               PI~OBLEM NOT LISTED ABOVE THAT YOU THINK
                                                                                               I SHOULD KNOW ABOUT                , ,
                                                                                                                                    - -
                                                                                                                                                    ,.                     =         -
                                                                                                                                                                                         0
                                                                   j'   ••
                                                                                          WOMEN         ONLY:
 9.     DO YOU BrWISE EASILY               , , . . . ..                       n     r-:      ARE YOU PREGNANT OR THINK YOU MAY BE PI~EGNANT ' "                             L:,          -
 10.    HAVE YOU EVER REQUIRED A BLOOD TRANSFUSION                            0     o        ARE YOU NUI~SING , , , ... , . , , , , , .... , , , , , , , , .. , , . ,                    -
                                                                                                                                                                                             ,

 11.    HAVE YOU HAD A RECENT WEIGHT LOSS. . . . ..                           rl    ,]
                                                                                             ARE YOU TAKING BIRTH CONTROL PILLS. . . . . . . . . . ..                       ~            -
                                                                                                                                                                                         I    '




                                                                             YES   NO                                                                                      YES       NO
  ARE YOU ALLERGIC             TO OR HAVE YOU HAD                               HIVES OR SKIN RASH, , , .. , . , , , , . ,                          . . . .   . . ..        0            -
  REACTIONS TO:                                                                 FAINTING Ol~ DIZZY SPELLS                                                 '   . . ..        [    1
    LOCAL ANESTHETICS LIKE NOVOCAINE .. , , ....                     U
                                                                      -,
                                                                            fl  DIABETES             , , ,               ' . ' ,                          '   ' , "         n            li
    PENICILLIN Ol~ OTHER ANTIBIOTICS, , . , , , , , ..               ~             n
                                                                                AIDS OR HIV INFECTION . ' . ' , .. ' , ,                            ' ,           "         11
                                                                                                                                                                                         --=


    SULFA DIWGS       ,                               , ,          .        0u  THYROID PROBLEMS                           , . .                    . . . .   . . ..        [l
    BARBITURATES, SEDATIVES OR SLEEPING PILLS, . 0                          U   ALLERGIES .. , . . . . . . . . . . . . . . . . .                    . . . .   . . ..        0            n
    ASPIRIN,            , , , ,                                    . L'     0   ARTHRITIS OR RHEUMATISM                         ,                   '                  ,    [J           n
    IODINE,           "                                            .     I   r
                                                                            Ll  JOINT REPLACEMENT OR IMPLANT                                                , , "           n            n
                                                                            r-
    ANY METALS (E.G., NICKEL, MEI~CUI~Y, ETe.), , ..                         n  STOMACH ULcm                   , . . . . . . . .                    . . . . . . ..          U            u
    LATEX / RUBBER . , , , . ,                ,                    . [          KIDNFY TROUBLE                                                            , . . ..          [J           I I
    OTHER (PLEASE LIST)
  DO YOU HAVE OR H'-AV-E==-::-cYO-=-:-U--=E-V=ER::---c:-cH-A-D--=T-H=E------
                                                                                TUBEI~CULOSIS '                ,             ,                                         ,    n            n
                                                                                PERSISTENT COUGH . . . . . . . . . . . . .                          . . . . . . ..          n            n
  FOLLOWING:                                                                    COUGH THAT PRODUCES BLOOD ....                                      ' . . . . . ..          n            n
    RHEUMATIC HEAI~T DISEASE OR ImEUMATlC FEV£I<                             n  CHEMOTHERAPY (CANCER, LEUKEMIA)                                     .....     , ..          n            n
    SCARLET FEVER         ,           , ,             , . . . . ..   [' 'J  L   SEXUALLY TRANSMITTED DISEASE. . . .                                 . . . . . . ..          [I           L   J
    HEART DEFECT OR HEART MURMUR . . . . . . . . ..                  U      L   EPILLPSY OR SEIIUI~ES                                                       , . . .              I       I    I
    HEART TROUBLE, HEART ATIACK, OR ANGINA . ..                      LJ     [l  ANEMIA, ,                                                                          .                          I
    CHEST PAIN                          ,             , , . . . ..           rl
                                                                            I-l GLAUCOMA         , .. ,                                                   ,                 ~            ~
    SHORTNESS OF BREATH. , , . , , , , , . , . , , , . . ..          0      U   NEINOUSNESS              ,                                                         .
                                                                                                                                                                                         c.J
    PACEMAKER           ,                         , . . . . . . ..   0      LJ  TONSILlITIS          , . ,             , . . . .                    . . . . . . ..          "----'       U
    HEART SURGERY. , , , .. , , , , , , . . . . . . . . . . ..       U      U   TUMor~s, ,             , ,             , ,                                ,        .                     0
    HIGH/LOW BLOOD PRESSURE "                             , . . ..   0             o
                                                                                MENTAL HEALTH CARE,                    , . . . .                    . . . . . . . .             _        L
    CONGENITAL HEAln pr~OBLEM. ,                        ' . , . ..   'I            n
                                                                                BACK PROBLEMS .. , ,               , , , . ,                                ,      .                     U
    SWELLING OF FEET,ANKLES, HANDS. , . . . . . . ..                 'I     [l  CHEMICAL DEPENDENCY                      , ,                                , . ..          L~           [_ J
    HEPATITIS, JAUNDICE OR LIVER DISEASE .. , . . ..                 :::::]        u
                                                                                MITRAL VALVE PROLAPSE                    , ,                              , . . ..          LJ           U
    STROKE          , , , , . . . . . . . . . . . . . . . . . . ..   ~             n
                                                                                CORTISONE TREATMENT                                                 ,       , . ..          r]           0
    SINUS TROUBLE                             '                 "            ::l   n
                                                                                COLD SORES/FEVER BLISTERS. , , ,                                       ,      , ..          0            0
    LUNG OR BREATHING PROBLEMS. . . . . . . . . . ..                 ~             o
                                                                                HYPOGLYCEMIA                           , , , ..                     , .. , , , .,           U            U
    ASTHMA OR HAY FEVER                         ,       , , .. ,.    0             o
                                                                                EATING DlsormERS                         ,                                , , . ,.          0            0
ITEM 07..Q515775/27011



                                                                                                                                                   PATIENT'S               NUMBER
                              Oral Screening Consent Form
 Complete each time the examination is performed and place in the patient's file


Our practice continually looks for advances to ensure that we are providing the optimum level of oral
health care to our patients. We are concerned about oral cancer and look for it in every patient.

One American dies every hour from oral cancer. Late detection of oral cancer is the primary cause that
both the incidence and mortality rates of oral cancer continue to increase. As with most cancers, age is the
primary risk factor for oral cancer. Tobacco and alcohol use are other major predisposing risk factors but
more than 25% of oral cancer victims have no such lifestyle risk factors. Studies also suggest that
human papillomavirus (HPV 16/18) plays a role in more than 20% of oral cancer cases: Oral cancer risk
by patient profile is as follows:

               Increased risk: patients ages 18-39
                                        ,
                                  -sexually active patients (HPV 16/18)
                   High risk: patients age 40 and older; tobacco users (ages 18-39, any type within 10 years)
                Highest risk: patients age 40 and older with lifestyle riskfactors (tobacco and/or alcohol use);
                               previous history of oral cancer

We have recently incorporated Vizil.ite" Plus into our oral screening standard of care. We find that using
ViziLite Plus along with a standard oral cancer examination improves the ability to identify suspicious areas
at their earliest stages. ViziLite Plus is similar to proven early detection procedures for other cancers such as
mammography, Pap smear, and PSA. ViziLite Plus is a simple and painless examination that gives the best
chance to find any oral abnormalities at the earliest possible stage. Early detection of pre-cancerous tissue
can minimize or eliminate the potentially disfiguring effects of oral cancer and possibly save your life.
The ViziLite Plus exam will be offered to you annually.

This enhanced examination is recognized by the American Dental Association code revision committee as
CDT-2007 /08 procedure code D04 31; however, this exam might not be covered by your insurance. The fee
for this enhanced examination is      _


No. I would prefer not to have the ViziLite Plus exam at this time.

Printname:                                                                              _

Signature:                                              Date:                            _



VLP004 - 2/06




• J Natl Cancer Inst. 2003 Dee 3;95(23):1772·83.
                                                                                             111'"""11'""   1111"11" 1111'""1111
                                                      ZILA-215-2008                          650602                       0608
Vizitlte'Plus B L
        OI\/tL


           ~U·J
                  lElte.


                 Bottor
                           I~U'I~lt""IOIii


                            $croonlng
                                             AIIII   ~"Rllli:'


                                             e ave s 11v&$*'
                                                                 'Y6~   ~


                                                                            WI::
                                                                                                       Patient                          _   10           _


                                                                                                       Clinician                    _       Oate         _




right                                                                              left                          right                           left




                                                                                                       buccal                                      buccal
                                                                                                       mucosa                                      mucosa




                                                                                      Highest Risk Sites                  tongue
                                                                                      Lateral border of tongue           (dorsum)
                                                                                      Lip
                                                                                      Anterior floor of mouth                                    lateral border
                                                                                      Soft palate