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General Information

Patients new to the warm, inviting office of Karisha L. Madden, DDS can make their customized dental experience even better when they complete our patient forms beforehand. We offer these forms online so you can fill them out in the comfort of your own home.

Please take a moment to fill out our New Patient Information.
 
Name:

*

Please enter your full name.
 
Nickname

Preferred Nickname:
 
Address:

Please enter complete address, city, state, zip.
 
Age: *

 
Were you referred? *

     
 
Who can we thank for the referral?

 
Do you have Dental Insurance? *


 
How would you rate the condition of your mouth? *


 
Who was your previous dentist? *

 

How long were you a patient of theirs? *

 
Date of your most recent dental exam: *

 
Date of your most recent x-rays: *

 
Date of your most recent dental treatment: *

(Other than a cleaning)
 
I routinely see my dentist every: *


 
Who is your physician and what is their specialty? *

 
When was your most recent physical exam? *

 
What was the purpose of your exam? *

 
What is your estimate of your general health? *


 
What is your immediate concern? *

 
Personal History

Please answer the following yes or no questions about your personal history.
 
Are you fearful of dental treatment? *

     
 
How fearful, on a scale of 1 to 10? *

 
Have you had an unfavorable dental experience? *

     
 
Have you ever had complications from past dental treatment? *

     
 
Have you ever had trouble getting numb or had any reactions to local anesthetic? *

     
 
Did you ever have braces, orthodontic treatment or had your bite adjusted? *

     
 
Which one, and at what age? *

 
Have you had any teeth removed, missing teeth that never developed or lost teeth due to injury or facial trauma? *

     
 
Gum and Bone Information

Please answer the following questions yes or no about your gums and bones.
 
Do your gums bleed or are they painful when brushing or flossing? *

     
 
Have you ever been treated for gum disease or been told you have lost bone around your teeth? *

     
 
Have you ever noticed an unpleasant taste or odor in your mouth? *

     
 
Is there anyone with a history of periodontal disease in your family? *

     
 
Have you ever experienced gum recession? *

     
 
Have you ever had any teeth become loose on their own (without an injury), or do you have difficulty eating an apple? *

     
 
Have you experienced a burning or painful sensation in your mouth not related to your teeth? *

     
 
Tooth Structure

Please answer the following yes or no questions about your tooth structure.
 
Have you had any cavities within the past 3 years? *

     
 
Does the amount of saliva in your mouth seem too little or do you have difficulty swallowing any food? *

     
 
Do you feel or notice any holes (i.e. pitting, craters) on the biting surface of your teeth? *

     
 
Are any teeth sensitive to hot, cold, biting, sweets, or do you avoid brushing any part of your mouth? *

     
 
Do you have grooves or notches on your teeth near the gum line? *

     
 
Have you ever broken teeth, chipped teeth, or had a toothache or cracked filling? *

     
 
Do you frequently get food caught between teeth? *

     
 
Bite and Jaw Joint

Please answer the following questions about your bite and jaw joint.
 
Do you have any problems with your jaw joint? *

(pain, sounds, limited opening, locking, popping)
     
 
Do you feel like your lower jaw is being pushed back when you try to bite your back teeth together? *

     
 
Do you avoid or have difficulty chewing gum, carrots, nuts, bagels, baguettes, protein bars, or other hard, dry foods? *

     
 
In the past 5 years, have your teeth changed (become shorter, thinner or worn) or has your bite changed? *

     
 
Are your teeth becoming more crooked, crowded or overlapped? *

     
 
Are your teeth developing spaces or becoming more loose? *

     
 
Do you have trouble finding your bite, or need to squeeze, tap your teeth together, or shift your jaw to make your teeth fit together? *

     
 
Do you close your tongue between your teeth or close your teeth against your tongue? *

     
 
Do you chew ice, bite your nails, use your teeth to hold objects, or have any other oral habits? *

     
 
Do you clench or grind your teeth together in the daytime or make them sore? *

     
 
Do you have any problems with sleep (i.e. restlessness or teeth grinding), wake up with a headache or an awareness of your teeth? *

     
 
Do you wear or have you ever worn a bite appliance? *

     
 
Smile Characteristics

Please answer the following questions about your smile characteristics.
 
Is there anything about the appearance of your teeth that you would like to change (shape, color, size)? *

     
 
Have you ever whitened (bleached) your teeth? *

     
 
Have you felt uncomfortable or self conscious about the appearance of your teeth? *

     
 
Have you been disappointed by the appearance of your previous dental work? *

     
 
Medical History

Please answer the following questions about your medical history.
 
Have you ever been hospitalized for illness or injury? *

     
 
Do you have or have you ever had an allergic or bad reaction to any of the following? *


 
Please let us know which items you are allergic to. *

 
Do you have or have you had heart problems or a cardiac stent within the last 6 months? *

     
 
Do you have or have you ever had infective endocarditis? *

     
 
Do you have an artificial heart valve or repaired heart defect (PFO)? *

     
 
Do you have a pacemaker or implantable defibrillator? *

     
 
Do you have an orthopedic implant (joint replacement)? *

     
 
Do you have or have you ever had rheumatic or scarlet fever? *

     
 
Do you have or have you ever had high or low blood pressure? *

     
 
Have you ever had a stroke (taken blood thinners)? *

     
 
Do you have or have you ever had anemia or another blood disorder? *

     
 
Have you ever had prolonged bleeding due to a slight cut (INR > 3.5) *

     
 
Do you have or have you ever had pneumonia, emphysema, shortness of breath, or sarcoidosis? *

     
 
Do you have or have you ever had chronic ear infections, tuberculosis, measles, or chicken pox? *

     
 
Do you have or have you ever had asthma? *

     
 
Do you have or have you ever had breathing or sleep problems (i.e. sleep apnea, snoring, sinus)? *

     
 
Do you have or have you ever had kidney disease? *

     
 
Do you have or have you ever had liver disease? *

     
 
Do you have or have you ever had jaundice? *

     
 
Do you have or have you ever had thyroid, parathyroid disease, or calcium deficiency? *

     
 
Do you have or have you ever had a hormone deficiency? *

     
 
Do you have diabetes? *

     
 
What's your HbA1c? *

 
Do you have or have you ever had stomach or duodenal ulcers? *

     
 
Do you have high cholesterol or are you taking statin drugs? *

     
 
Do you have or have you ever had any digestive or eating disorders? *

(e.g., celiac disease, gastric reflux, bulimia, anorexia)
     
 
Do you have osteoporosis or osteopenia? *

(i.e. taking bisphosphonates)
     
 
Do you have arthritis? *

     
 
Do you have an autoimmune disease? *

(i.e. rheumatoid arthritis, lupus, scleroderma)
     
 
Do you have glaucoma? *

     
 
Do you wear contact lenses? *

     
 
Do you have or have you ever had any head or neck injuries? *

     
 
Do you have epilepsy or have you ever had convulsions (seizures)? *

     
 
Do you have any neurologic disorders? *

(ADD/ADHD, prion disease)
     
 
Do you have or have you ever had any viral infections or cold sores? *

     
 
Do you have or have you ever had any lumps or swelling in the mouth? *

     
 
Do you have or have you ever had hives, skin rash, or hay fever? *

     
 
Do you have or have you ever had an STI/STD/HPV? *

     
 
Do you have or have you ever had hepatitis? *

     
 
What type? *

 
Do you have HIV/AIDS? *

     
 
Do you have or have you ever had a tumor or abnormal growth? *

     
 
Are you currently undergoing or have you been treated with radiation therapy? *

     
 
Are you currently or have you ever been treated with chemotherapy or immunosuppressive medication? *

     
 
Do you have now or have you ever had emotional difficulties? *

     
 
Are you currently or have you ever undergone psychiatric treatment? *

     
 
Are you now or have you ever been on antidepressant medication? *

     
 
Do you now or have you ever used alcohol or recreational drugs? *

     
 
Are you presently being treated for any other illness? *

     
 
Are you aware of a change in your health in the last 24 hours? *

(i.e. fever, chills, new cough, or diarrhea)
     
 
Are you taking medication for weight management? *

     
 
Are you taking any dietary supplements? *

     
 
Are you often exhausted or fatigued? *

     
 
Are you experiencing frequent headaches? *

     
 
Are you a smoker? Have you smoked previously or use(d) smokeless tobacco? *

     
 
Are you considered a touchy or sensitive person? *

     
 
Are you often unhappy or depressed? *

     
 
Are you taking birth control pills? *

     
 
Are you currently pregnant? *

     
 
Have you been diagnosed with a prostate disorder? *

     
 
Please describe any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment. *

(i.e. Botox, Collagen injections)
 
Please list all medications, supplements, and/or vitamins taken within the last two years. *

Please list the drug and purpose and add a line break between each drug.
 
Please advise us in the future of any change in your medical history or any medications you may be taking.

 
HIPAA Notice of Privacy Practices

   This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please review the following carefully.
   The Health Insurance Portability & Accountability Act of 1996 (HIPAA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. The Act gives you, the patient, significant new rights to understand and control how your information is used. HIPAA provides penalties for covered entities that misuse personal health information.
   As required by HIPAA, we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information.
   We may use and disclose your medical records for several purposes, including treatment, payment, defense of legal matters, to family and friends, and health care operations:
     -Treatment includes providing, coordinating, and/or managing health care related services by one or more health care providers. An example of this would include teeth cleaning services.
     -Payment includes such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a claim for your visit to your insurance company for payment.
     -Health care operations include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review. We may also create and distribute de-identified health information by removing all references to individually identifiable information.
     -To Your Family and Friends: We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare. Before we disclose your health information to these people, we will provide you with an opportunity to object to our use or disclosure. If you are not present, or in the event of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We may use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, X-rays, or other similar forms of health information. We may use or disclose information about you to notify or assist in notifying a person involved in your care, of your location and general condition.

   In some limited situations, the law allows or requires us to use/disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all.
   Such uses or disclosures are:
     -When a state or federal law mandates that certain health information be reported for a specific purpose
     -For public health purposes, such as contagious disease reporting, investigation or surveillance, and notices to and from the federal Food and Drug Administration regarding drugs or medical devices
     -Disclosures to governmental authorities about victims of suspected abuse, neglect, or domestic violence
     -Uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws
     -Disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies
     -Disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else
     -Disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations
     -Uses or disclosures for health-related research
     -Uses and disclosures to prevent a serious threat to health or safety
     -Uses or disclosures for specialized government functions, such as for the protection of the president or high-ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service
     -Disclosures of de-identified information
     -Disclosures relating to worker's compensation programs
     -Disclosures of a "limited data set" for research, public health, or healthcare operations
     -Incidental disclosures that are an unavoidable by-product of permitted uses or disclosures
     -Disclosures to "business associations" who perform healthcare operations for our office and who commit to respect the privacy of your health information

   We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. If you wish to be omitted from any mailings please provide a written notice. Any other uses and disclosures will be made only with your written authorization. You may revoke such authorization in writing and we are required to honor and abide by that written request, except to the extent that we have already taken actions relying on your authorization.
   You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the Privacy Officer:
     -The right to request restrictions on certain uses and disclosures of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other person identified by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
   -The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
   -The right to inspect and copy your protected health information.
   -The right to amend your protected health information.
   -The right to receive an accounting of disclosures of protected health information.
   -The right to obtain a paper copy of this notice from us upon request.

   We are required by law to maintain the privacy of your protected health information and provide you with notice of our legal duties and privacy practices with respect to protected health information.
   This notice is effective as of May 4, 2017, and we are required to abide by the terms of the Notice of Privacy Practices currently in effect.
   We reserve the right to change the terms of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices from this office.
   If you think that we have not properly respected the privacy of your health information or that your privacy protections have been violated, you have the right to file a written complaint to us or the U.S. Department of Health and Human Services, Office for Civil Rights, about violations of the provisions of this notice or the policies and procedures of our office. We will not retaliate against you for filing a complaint.
   For more information about HIPAA and/or to file a complaint, please call or visit or office or contact:

The U.S. Dept of Health & Human Services, Office for Civil Rights
200 Independence Avenue, S.W. Washington D.C. 20201
(202) 619-0257 Toll Free: 1-877-696-6775



 
HIPAA Patient Consent Form

  I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (a.k.a. HIPAA or The Healthcare Privacy Act). I understand that by signing this consent, I authorize Madden Dental to use and/or disclose my protected health information to carry out the following:
     -Treatment which includes direct and/or indirect treatment by other healthcare providers involved in my treatment.
     -Obtaining payment from third party payers, i.e. my dental and/or medical insurance company/companies.
     -The day to day healthcare operations of your dental practice.
   Additionally, I authorize you to share all my protected health information with the following individual(s): *

Please enter the Name, Relationship, and Phone Number for any individuals you wish for us to share information with
 
I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected personal health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may request the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and healthcare operations, but that you are not required to agree to use these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent will not be affected. *

By clicking "I accept" you acknowledge receipt of our Privacy Practices.
     
 
Primary Insurance Coverage: *

Primary Holders Name:
Birthdate:
SSN#
ID#
Relationship to patient:
Employed By:
Insurance Carrier:
Group#
Insurance Provider Phone Number:
Thank you for filling out our new patient information. 
We are excited to have you as a patient.
Please visit our website or give us a call if you have any questions.
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