Dr. Joseph Vaughan, D.D.S Patient registration Id: Chart Id: First Name: Last Name: Middle Initial: Patient Is: Policy Holder Responsible Party Preferred Name: Responsible Party ( if someone other than the patient ) First Name: Last Name: Middle Initial: Address: Address 2: City State Zip Home Phone: Work Phone: Ext: Cellular: Pager: Birth Date: Soc Sec: Drivers Lic: Responsible Party is also a Policy Holder for Patient: Responsible Party is also a Policy Holder for Patient: Primary Insurance Policy Holder: Secondary Insurance Policy Holder: Patient Information Address: Address 2: City State Zip Home Phone: Work Phone: Ext: Cellular: Pager: Sex Male Female Marital Status: Married Single Divorced Separated Widowed Birth Date: Age: Soc Sec: Drivers Lic: E-mail: I would like to receive correspondences via e-mail. Section 2 Employment Status: Full Time Part Time Retired Student Status: Full Time Part Time Medicaid Id: Pref. Dentist: Employer Id: Pref. Pharmacy: Carrier Id: Pref. Hyg: Primary Insurance Information Name of Insured: Relationship to Insured: Self Spouse Child Other Insured Soc. Sec: Insured Birth Date: Employer: Address: Address 2: City: State: Zip: Ins. Company: Address: Address 2: City: State: Zip: Rem. Benefits: Rem. Deduct: Secondary Insurance Information Name of Insured: Relationship to Insured: Self Spouse Child Other Insured Soc. Sec: Insured Birth Date: Employer: Address: Address 2: City: State: Zip: Ins. Company: Address: Address 2: City: State: Zip: Rem. Benefits: Rem. Deduct:   Dr. Joseph Vaughan, D.D.S Medical History Although dental personnel primarily treat 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. Are you under a physician's care now? Yes No If yes Have you ever been hospitalized or had a major operation? Yes No If yes Have you ever had a serious head or neck injury? Yes No If yes Are you taking any medication, pills, or drugs? Yes No If yes Do you take, or have you taken, Phen-Fex or Redux? Yes No If yes Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? Yes No If yes Are you on a special diet? Yes No Do you use tobacco? Yes No Women: Are you... Pregnant/Trying to get pregnant? Nursing? Taking oral contraceptives? Are you allergic to any of the following? Acrylic Aspirin Codeine Latex Metal Penicillin Sulfa Drugs Local Anesthetics Other: Do you use controlled substances? Yes No If yes Do you have, or have you had, any of the following? Yes No AIDS/HIV Positive Alzheimer's Disease Anaphylaxis Anemia Angina Arthritis/Gout Artificial Heart Valve Artificial Joint Asthma Blood Disease Blood Transfusion Breathing Problems Bruise Easily Cancer Chemotherapy Chest Pains Cold Sores/Fever Blisters Congenital Heart Disorder Convulsions Yes No Cortisone Medicine Diabetes Drug Addiction Easily Winded Emphysema Epilepsy or Seizures Excessive Bleeding Excessive Thirst Fainting Spells/Dizziness Frequent Cough Frequent Diarrhea Frequent Headaches Genital Herpes Glaucoma Hay Fever Heart Attack/Failure Heart Murmur Heart Pacemaker Heart Trouble/Disease Yes No Hemophilia Hepatitis A Hepatitis B or C Herpes High Blood Pressure High Cholesterol Hives or Rash Hypoglycemia Irregular Heartbeat Kidney Problems Leukemia Liver Disease Low Blood Pressure Lung Disease Mitral valve Prolapse Osteoporosis Pain in Jaw Joints Parathyroid Disease Psychiatric Care Yes No Radiation Treatments Recent Weight loss Renal Dialysis Rheumatic Fever Rheumatism Scarlet Fever Shingles Sickle Cell Disease Sinus Trouble Spina Bifida Stomach/Intestinal Disease Stroke Swelling of Limbs Thyroid Disease Tonsillitis Tuberculosis Tumors or Growths Ulcers Venereal Disease Yellow Jaundice Have you ever had any serious illness not listed above? Yes No If yes Comments: To the best of my knowledge, the questions on this form have been correctly answered. I understand that providing incorrect information can be dangerous to my (or the patients) health. It is my responsibility to inform the dental office of any changes in my medical status. Date   Dr. Joseph Vaughan, D.D.S Acknowledgement of Receipt of Notice of Privacy Policies I have received a copy of the Notice of Privacy of Joseph G. Vaughan. I hereby authorize, as indicated by my signature below, Joseph G. Vaughan to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose, as authorized in the Patient Consent form. Patient Name: Address: Signature: Date: Please chek all your preferred mean of communication: You may contact me at my home telephone number: You may contact me on my mobile telephone number: You may contact me on my work telephone number: You may send me an unencrypted email at: You may send me a text at: Please list authorized persons with whom we may discuss your Protected Health Information (PHI) in addition to custodial parents and legal guardians: 1. Date Added / Removed: 2. Date Added / Removed: 3. Date Added / Removed: 4. Date Added / Removed: For Office Use Only: We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: ____ Individual refused to sign ____ Communication barriers prohibited obtaining the acknowledgement ____ An Emergency situation prevented us from obtaining the acknowledgement ____ Other (Please Specify) Staff Person Initials   Dr. Joseph G. Vaughan 130 Cedar Knoll Ronceverte, WV 24970 304-645-2333 304-647-5932 (fax) Website: www.drjosephvaughan.com Office & Financial Agreement This is an agreement between Dr. Joseph Vaughan DDS and the Responsible Party named on this form. Statements: If you have a balance on your account, we will send you a monthly statement. It will show separately the previous balance, any new charges to the account, and any payments or credits applied to your account during the month. After 60 days your account will be charged a 5% finance charge for all unpaid estimated portions owed by you but not yet paid. This finance charge will accrue monthly until the balance is paid in full. Payment options if you have treatment over $400.00-only when arranged in advance of treatment beginning: A. Payment by cash, check, or credit card on the day that the treatment is rendered. We accept Visa, MasterCard, Discover, and American Express. B. One month financing with credit card on file or 1 held check. With this option, you must be pre-approved by the office and complete and sign the appropriate forms. C. On treatment involving laboratory fees (crowns, bridges, dentures, etc.) you pay 50% on the preparation date and the balance in three weeks or when appliance is delivered, whichever comes first. D. All treatment completed under oral conscious sedation must be paid in full before treatment is rendered. E. 3rd party payment options. Care Credit brochures are available at the front desk. Insurance: Insurance is contract between you and your insurance company. We are NOT a party to this contract. We do bill your primary insurance company as a courtesy to you. Although we estimate what your insurance company may pay, it is the insurance company that makes the final determination of your payment. You agree to pay any portion of the charges not covered by insurance. If your insurance company fails to pay within 60 days, the full remaining balance is then due by you. Required payments: Any estimated patient portion, which includes co-pay and deductible, must be paid at time of service. Return checks: There is a $25.00 fee for any checks returned by the bank. Collections: There is a $25.00 non-refundable charge to your account if your account is referred to our Accounts Receivable Company. These are accounts with a 60 day patient responsibility balance. Confirm/Missed appointments: We ask for all appointments to be confirmed 2 business days in advance or we reserve the right to cancel any appointment not confirmed within 2 business days. We ask that you please give our office no less than 2 business days, in the event you are unable to keep your appointment commitment. We reserve the right to charge $25.00 for a failed appointment. Failing to cancel a Sedation appointment 48 hours in advance can result in a $260.00 charge. Providing less than 48 hours does not allow us an opportunity to offer the reserved time to a patient having an immediate need. Therefore, we consider your appointment as a failed or a "no show". If this should happen twice, we will provide a written notice as a reminder to you that on the third time we have no options but to discontinue our doctor/patient relationship. This allows you to seek an office that may provide you with more preferred hours. For First Time Patients, we will allow one failed or "no show" appointment, at which time you will receive a written notice as a reminder to you that on the next failed or "no show" appointment we will no longer reschedule you. We care very much about our patients and our ability to provide comprehensive care. Comprehensive care is care delivered on a regular basis and keeps your patient status as "active". In the event you do not return to the office within a two year period, we will consider your status "inactive" & no longer a patient of record. Any appointments that are needed will be made when scheduling permits through our hygiene department first. If you no longer a patient of record, we will keep your records for a period of 7 years. Divorce: In case of divorce or separation, the party responsible for the account prior to the divorce or separation remains responsible for the account. After a divorce or separation, the parent authorizing treatment for a child will be the parent responsible to collect from the other parent. Transferring of records: You will need to make your request in writing. The records will be available 7 days from receiving request. If you are requesting your records be transferred from another doctor or organization to us, you authorize us to receive all relevant information. Signature Please enter code above in the field below.