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Tell Us About Yourself

FORM 1 of 3 - New patients please complete forms 1 3

Legal name: _____________________________________________ (Circle one)

Mr.

Mrs.

How would you prefer to be addressed? _______________________ (Circle one)

Married

Ms.

Divorced

Miss
Widowed

Dr.
Single

Date of birth: _______________ SS #: _______________________


Address: ________________________________________________ City: _______________ State: ________ Zip: ________
Home Phone: _______________________ Cell Phone: ______________________ Business Phone: ____________________
Which number should we call first?

Home

Cell

Work

Employer/Occupation: ___________________________________

E-mail address: ___________________________________________________________________________________________


Full time student?

NO

YES

Name of School: ___________________________________________________________

Spouses name: ___________________________________________ Spouses Phone: ________________________________


Emergency contact: ___________________________ Phone #: ____________________ Relationship to patient: ____________
Who is your medical doctor? ___________________________________________ Phone #: ____________________________
Who was your previous dentist? ________________________________________ Phone #: _____________________________
Who may we thank for referring you? __________________________________________________________________________
Primary Dental Insurance (please be prepared to present your insurance card(s) upon your first visit):
Dental Insurance: __________________________________________________ Group #: ______________________________
Claims Address: ___________________________________________ City: _______________ State: _______ Zip: ________
Claims Phone #: ____________________________ Subscribers Employer/Occupation: ________________________________
Subscribers Name: ________________________________________ Relationship to patient: ___________________________
Subscribers Date of birth: ________________

Subscribers SS #: ___________________ ID #: ________________________

Secondary Dental Insurance:


Dental Insurance: __________________________________________________ Group #: ______________________________
Claims Address: ___________________________________________ City: _______________ State: _______ Zip: ________
Claims Phone #: ____________________________ Subscribers Employer/Occupation: ________________________________
Subscribers Name: ________________________________________ Relationship to patient: ___________________________
Subscribers Date of birth: ________________

Subscribers SS #: ___________________ ID #: ________________________

Authorization and Payment Agreement:


We believe we have a responsibility to provide the best professional care, skill and judgment in planning
and delivering your dental treatment. Your payment will reimburse us for our services. By signing below,
you are indicating that after all fees are properly explained to you that you agree to fulfill your financial
commitment to our office promptly and completely.
I hereby authorize my insurance company to make payments directly to the office of Dr. Glenn D. Krieger.
If I should receive an insurance check, and I have an outstanding balance, I agree to immediately endorse
and remit the check to the dental office. I understand that I am responsible for all costs of dental treatment
regardless of insurance payments or lack thereof. I hereby authorize the dental office to administer such
medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary
for proper dental care. The information on this page and the dental/medical histories are correct to the best
of my knowledge. I grant the right to the dentist to release my dental/medical histories and other
information about my dental treatment to third party payers and/or other health professionals. I understand
any photos taken may be used for educational or promotional purposes by the office of Dr. Glenn D.
Krieger.

Signature (if minor, responsible party) __________________________________________________

Date _________________

MEDICAL HEALTH HISTORY


Do you have, or have you had, any of the following?
FORM 2 of 3

_____________________________________Yes
High Blood Pressure
_
Is it currently under control?

No
_
_

Last checked _________________________________


Heart Disease
Is it currently under control?

No
_

When? ___________________________________
Diagnosed with Hepatitis

When? ___________________________________

Type? ____________________________________

When? ______________________________________
Heart Murmur

Yes
_

Last checked _________________________________


Stroke

____________________________________
History of Rheumatic fever

Diagnosed with HIV/AIDS

When? ___________________________________
Autoimmune Disorders (Lupus, etc.)

Chemotherapy or Radiation Therapy

When was it diagnosed? ________________________

When? ___________________________________

How was it diagnosed? _________________________

Reason? __________________________________

Any follow-up tests?

Prolapsed Mitral Valve

How much? _______________________________

When was it diagnosed? ________________________

For how long? _____________________________

How was it diagnosed? _________________________

Still smoking?

Any follow-up tests?

History of Smoking?

What happened? ___________________________

Last Seizure? _________________________________

_________________________________________

Seizures or Epilepsy

Diabetes

Allergy or Sensitivity to Latex

Asthma/Respiratory Disorders

When was it diagnosed? ________________________

When was it diagnosed? _____________________

How is it controlled? ____________________________

How is it controlled? _________________________

Fainting or Dizziness
_
_
When? ______________________________________
Any diagnosis or treatment for this condition? ____________________________________________________________
Do you drink alcohol?
_
_
How many alcoholic beverages do you consume in an average week? ________________________________________
History of Psychiatric Care
_
_
Currently?
_
_
Medications ______________________________________________________________________________________
Joint Replacement Surgery
_
_
When? ______________________________________
Treating Surgeons Name & City ______________________________________________________________________
Surgical Pins/Rods Placed?
_
_
When? ______________________________________
Treating Surgeons Name & City ______________________________________________________________________
Has your physician mentioned the need for antibiotics when you visit the dentist?
History of ailments or diagnosis not listed affecting the:

If yes, please explain:

Liver
_
_
_______________________________________________
Joints
_
_
_______________________________________________
Lungs
_
_
_______________________________________________
Heart
_
_
_______________________________________________
Gastrointestinal
_
_
_______________________________________________
Eyes
_
_
_______________________________________________
Ears
_
_
_______________________________________________
Nose
_
_
_______________________________________________
Throat
_
_
_______________________________________________
Allergies: ___________________________________________________________________________________________
Current Medications: _________________________________________________________________________________

Signature (Guardian if patient is a minor) ________________________________________

Date ___________________

DENTAL HEALTH HISTORY


FORM 3 of 3
________________________________________Yes

No

Are you apprehensive about dental treatment? ___________ _

Have you had problems with previous dental treatment? ___ _

Ever feel tired? _________________________________ _

Do you gag easily? ________________________________ _

Hurt when you chew or open wide to take a bite? ______ _

Does food catch between your teeth? _________________ _

Have pain or discomfort that affects your appetite,

Do you have difficulty in chewing your food? ____________ _

sleep or routine? ________________________________ _

Do you chew on only one side of your mouth? ___________ _

Ever pop, click or get stuck when you open? _________ _

__

______ _______________Yes

No

Does your jaw

Do you avoid brushing any part of your mouth

If so, how often? ____________________________

because of pain? ______________________________ _

Do your gums bleed easily? _________________________ _

How long has it been happening? ______________


Do you

Do your gums feel swollen or tender? ________________ _

Often wake up with a sore neck? ___________________ _

Are your teeth sensitive? ___________________________ _

Often suffer from headaches? _____________________ _

Have earaches or pain in front of the ears? ___________ _

Do you feel twinges of pain when your teeth come in


contact with:
Hot foods or liquids? _______________________ _

Notice your teeth wearing down at all? ______________ _

Ever have pain in you jaw muscles? ________________ _

Cold foods or liquids? ______________________ _

Clench or grind your teeth during the day? ____________ _

Sours? _________________________________ _

Know if you grind your teeth while you sleep? _________ _

Sweets? ________________________________ _

Wear an appliance to prevent damage from nighttime

Do you have any teeth that spontaneously ach or throb? __ _

grinding? If so, when was it made? __________________ _

Do you prefer to save your teeth? _____________________ _

Does your bite ever feel different when you wake up? ______ _

Do you want complete dental care? ___________________ _

Are you a habitual gum chewer or pipe smoker? ___________ _

Have you ever been treated by a periodontist? _________ _

Have you ever been treated by an orthodontist? __________ _

If yes, when? ________________________________

If yes, when? ___________________________________

For what reason? _____________________________

For what reason? ________________________________

Do you have any missing teeth that have not been

Has there been any recommended dental treatment that

replaced? If yes, why? ________________________

was not accomplished? If so, what prevented it? _____ _

____________________________________________

______________________________________________

When was the last time you saw a dentist for a regular checkup (best guess)? __________________________________________
When was your last dental cleaning (best guess)? _______________________________________________________________
How many times a year did your previous dentist recommend you have a professional cleaning? __________________________

What are your future dental health goals? ________________________________________________________________________


What would you change about the appearance of your teeth if you could? ______________________________________________
What has prevented you from making these changes? _____________________________________________________________

On a scale of 1-10 (with 10 being the highest) what is your level of dental anxiety? _______________________________________
On a scale of 1-10 (with 10 being the highest) how would you rate your current level of dental health? _______________________
If you answered less than 10, what in your mind keeps you from being there? __________________________________________

Do you have a chief dental concern at this time? ___________________________________________________________________


What dental issues not listed would you like to discuss with the doctor? ________________________________________________

Signature (Guardian if patient is a minor) ________________________________________________

Date _________________

I acknowledge that I have received a copy of the Notice of Privacy Practices for the offices of
Partners in Dental Excellence. The Notice of Privacy Practices describes the types of uses
and disclosures of my protected health information that might occur in my treatment, payment
for services or in the performance of offices health care operations. The Notice of Privacy
Practices also describes my rights and the responsibilities and duties of this office with respect
to my protected health information. The Notice of Privacy Practices is also posted in the
facility.
Glenn Krieger, DDS reserves the right to change the privacy practices that are described in the
Notice of Privacy Practices. If privacy practices change, I will be offered a copy of the revised
Notice of Privacy Practices at the time of my first visit after the revisions become effective. I
may also obtain a revised Notice of Privacy Practices by requesting that one be mailed to me.
ADDITIONAL DISCLOSURE AUTHORITY
In addition to the allowable disclosures described in the Notice of Privacy Practices, I hereby
specifically authorize disclosure of my protected health care information to the persons
indicated below.
ANY MEMBER OF MY IMMEDIATE FAMILY
YES
NO
SPOUSE ONLY

YES

NO

OTHER (PLEASE SPECIFY):

YES

NO

____________________________________
Name of Patient or Personal Representative

X_______________________________________
Signature of Patient or Personal Representative

_____________________
Date

________________________________________
Description of Personal Representatives Authority
OFFICE USE ONLY BELOW THIS LINE

Record of Acknowledgement not obtained

PROVIDED PRIOR TO TREATMENT?


DATE PROVIDED:_______________
REASON FOR DENIAL:

YES

NO

NEEDED MORE TIME TO REVIEW NOTICE OF PRIVACY PRACTICES


WANTED TO CONSULT WITH ANOTHER PERSON, BEFORE SIGNING
____UNABLE TO SIGN
____REASON NOT GIVEN
OTHER (EXPLAIN):

Date

To Whom It May Concern:


Our mutual patient ________________________________________ has
authorized the release of any recent x-rays (FMX or PANO in the last 5 years or
BWX in the last 2 years), recent periodontal charting and any other pertinent
dental or health information to our office.
Please forward the information to our office as soon as possible as our patient
has an appointment scheduled on ____________________.
If you have any questions or concerns, please feel free to contact me.
Thank you,

Theresa Sculley
New Patient/Hygiene Coordinator

Patient Signature_______________________________ DOB___________

4150 California Ave. SW


Seattle, WA 98116
206-935-1855 phone
206-937-3996 fax

STATEMENT OF PRIVACY PRACTICES


Our office is dedicated to protect the privacy rights of our patients and the confidential information
entrusted to us. The commitment of each employee to ensure that your health information is never
compromised is a principle concept of our practice. We may, from time to time, amend our privacy policies
and practices but will always inform you of any changes that might affect your rights.

Protecting Your Personal Healthcare Information


We use and disclose the information we collect from you only as allowed by the Health Insurance
Portability and Accountability Act and the state of Washington. This includes issues relating to your
treatment, payment, and our dental care operations. Your personal health information will never be
otherwise given to anyone even family members without your written consent. You, of course, may
give written authorization for us to disclose your information to anyone you choose, for any purpose.
Our offices and electronic systems are secure from unauthorized access and our employees are trained to
make certain that the confidentiality of your records is always protected. Our privacy policy and practices
apply to all former, current, and future patients, so you can be confident that your protected health
information will never be improperly disclosed or released.

Collecting Protected Health Information


We will only request personal information needed to provide our standard of quality dental care, implement
payment activities, conduct normal dental practice operations, and comply with the law. This may include
your name, address, telephone number(s), Social Security Number, employment data, medical history,
health records, etc. While most of the information will be collected from you, we may obtain information
from third parties if it is deemed necessary. Regardless of the source, your personal information will
always be protected to the full extent of the law.

Disclosure of your Protected Health Information


As stated above, we may disclose information as required by law. We are obligated to provide information
to law enforcement and governmental officials under certain circumstances. We will not use your
information for marketing purposes without your written consent.
We may use and/or disclose your health information to communicate reminders about your appointments
including voicemail messages, answering machines, and postcards.

Patient Rights
You have a right to request copies of your healthcare information; to request copies in a variety of formats;
and to request a list of instances in which we, or our business associates, have disclosed your protected
information for uses other than stated above. All such requests must be in writing. We may charge for
your copies in the amount allowed by law. If you believe your rights have been violated, we urge you to
notify us immediately. You can also notify the U.S. Department of Health and Human Services.
We thank you for being a patient at our office. Please let us know if you have any questions concerning
your privacy rights and the protection of your personal health information.

4150 California Ave. SW


Seattle, WA 98116
206-935-1855