858 Commercial St. NE, Salem OR 97301 | salemdentaloffice@gmail.com
 
 
Like Us:
 
 
 
 
Holly Chamberlain, DDS
 
Comprehensive and Esthetic Dentistry
 
Call Us Today
 
 
 
 
 
 
WELCOME! Thank you For Selecting Our Dental Team
 
 
Date:
 
 
 
 
 
 
 
 
Birth Date:
 
 
 
 
 
 
 
 
 
 
 
 
 
Spouse / Parent / Guardian Information
 
 
 
Birth Date:
 
 
 
 
 
 
 
 
Emergency Contact Not Living With You
 
 
 
 
Insurance Information
 
 
 
 
 
 
 
 
Birth Date:
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Birth Date:
 
 
 
 
 
 
Appointments: Our office understands how valuable your time is. We strive to have our patients seen on time. We accommodate your schedule as much as possible when making appointments. Valuable clinical time is lost when appointments are missed or cancelled with short notice (less than 24 hours). You will be charged $50.00 per appointment for no show or short notice cancellations.
If You Have Dental Insurance: Dental insurance policies are very different. Most require an annual deductible. We will give you an approximate dollar amount of your portion owing after insurance. Your portion of uncovered expenses are due at time of your appointment. We cannot guarantee insurance payment. You will be billed for total treatment charges for insurance non-payment which is 90 days past due.
If You Do Not Have Dental Insurance: Payment is required at the time dental services are performed. You are financially responsible for the services you receive.
I Have Read and Understand The Above Policies
 
 
 
Date:
 
 
 
 
 
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.
 
 
 
Date:
 
 
 
 
Do you have a primary physician?
 
 Yes  No 
 
If yes, please explain:
 
 
Are you currently being treated by a physician?
 
 Yes  No 
 
If yes, please explain:
 
 
Have you ever been hospitalized or had a majoroperation?
 
 Yes  No 
 
If yes, please explain:
 
 
Have you ever had a serious head or neck injury?
 
 Yes  No 
 
If yes, please explain:
 
 
Are you taking any medications, pills, or drugs?
 
 Yes  No 
 
If yes, please explain:
 
 
Do you take, or have you taken, Phen-Fen or Redux?
 
 Yes  No 
 
If yes, please explain:
 
 
Have you ever taken Fosamax, Boniva, Actonel orany other medications containing bisphosphonates?
 
 Yes  No 
 
If yes, please explain:
 
 
Are you on a special diet?
 
 Yes  No 
 
If yes, please explain:
 
 
Do you use tobacco?
 
 Yes  No 
 
If yes, please explain:
 
 
Do you use controlled substances?
 
 Yes  No 
 
If yes, please explain:
 
 
Are you Pregnant/Trying to get pregnant?
 
 Yes  No 
 
(Women)
 
 
Nursing?
 
 Yes  No 
 
(Women)
 
 
Taking oral contraceptives?
 
 Yes  No 
 
(Women)
 
Are you allergic to any of the following?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Do you have, or have you had, any of the following?
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Have you ever had any serious illness not listed above?
 
 Yes  No 
 
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
 
 
 
Date:
 
 
 
 
 
 
Date:
 
 
 
 
 
Notice of Privacy Practices (HIPAA)
I understand that, under the Health Insurance Portability & Accountability Act of 1996 (“HIPAA”), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:
  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.
I acknowledge that I can receive a copy of the Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization at anytime at the address above to obtain a current copy of the Notice of Privacy Practices.
 
 
 
Date: