Daniel Castro D.D.S, P.A

6901 Helen of Troy, BLDG. C

El Paso, Texas, 79911

915-581-8070

PATIENT INFORMATION

NAME:
SS #:
ADDRESS:
HOME PHONE:
CITY:
STATE:
ZIP:
CELL PHONE:
WORK PHONE:
E-MAIL:
DOB:
DRIVERS LICENSE #:
EMPLOYER'S NAME:
EMPLOYER'S ADDRESS:
CITY:
ZIP:

SPOUSE

NAME:
SS #:
DOB:
DRIVERS LICENSE #:
EMPLOYER'S NAME:
CELL PHONE:
EMPLOYER'S ADDRESS:
CITY:
ZIP:

PRIMARY DENTAL INSURANCE

EMPLOYER'S NAME:
ID #:
INSURANCE COMPANY:
PHONE:
INSURANCE CO.ADDRESS:
CITY:
STATE:
ZIP:
GROUP NUMBER:

SECONDARY DENTAL INSURANCE

EMPLOYER'S NAME:
ID #:
INSURANCE COMPANY:
PHONE:
INSURANCE CO.ADDRESS:
CITY:
STATE:
ZIP:
GROUP NUMBER:

PATIENTS REFERRAL INFORMATION

REFERRED BY:
IF REFERRED BY A FRIEND, MAY WE THANK HER OR HIM?
NAME OF PREVIOUS DENTIST:

EMERGENCY CONTACT

NAME Of PERSON NOT LIVING WlTH YOU:
RELATIONSHIP:
ADDRESS:
CITY:
STATE:
ZIP CODE:
PHONE NUMBER (HOME):
WORK NUMBER:

THE RULES AND REGULATIONS OF THE STATE OF TEXAS REQUIRES US TO KEEP ALL PATIENT RECORDS FOR 5 YEARS. PLEASE BE ADVISED SHOULD YOU RELOCATE AND NEED A COPY OF YOUR X-RAYS THERE WILL BE A DUPLICATION FEE OF $15 to $25 (RULE 108 SECTION G OF THE STATE BOARD OF DENTAL EXAMINERS), ALLOW TWO WEEKS FOR DUPLICATION.

Signature

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Date:

MEDICAL – DENTAL HISTORY

PATIENT'S NAME:
DOB:
SSN:

INSTRUCTIONS:

To receive treatment in this office you must answer all questions on this history form. The questions asked relate directly to the safe and effective treatment you are to receive in the office‐to the best of your ability honest answers must be given. If you are unsure of the questions, unsure of your answer, or whether the questions relate to your medical condition, you are to discuss the matter with the doctor. Some of the questions may not relate to your medical condition; in the event you are to write “N/A” (not applicable) in the space provided. All questions must be answered. To properly evaluate your current health status it may be necessary for the dentist to contact your physician. Included on this form is “Permission to Release Information.”Please sign it in the presence of a member of the office staff.
ALL INFORMATIONS YOU SUPPLY ON THIS FORM OR INFORMATION OBTAINED BY YOUR PHYSICIAN AND THE SUBSEQUENT INTERVIEW BY THE DENTIST WILL BE HELD IN THE STRICTEST CONFIDENCE, AND WILL NOT BE DISCLOSED WITHOUT YOUR WRITTEN PERMISSION.

Name of your physician and previous Dentist:
Date of last visit to your MD:
Purpose of visit:
Date of last visit to your dentist:
Do you suffer from any disability?
If yes, describe

PLEASE SELECT EACH OF THE FOLLOWING: YES OR NO
Rheumatic Fever
Joint Replacement (hip, knee etc)
Heart Murmur
Surgery
Type
YR
Arthritis/Rheumatism
Mitral Valve Prolapse
Hepatitis/Liver disease
Type
How long ago?
Glaucoma
HIV Positive/AIDS
Migraine Headache
Neck/Head Pain
Anemia/Blood Disease/Leukemia
Tuberculosis/Lung Disease
Kidney Dysfunction/ Disease/ Dialysis
Hay Fever/Allergies
Low Blood Pressure
High Blood Pressure
Do you use tobacco
PTSD
Implants (teeth, breast, hair, etc.)
Cancer
Radiation
Chemotherapy
Epilepsy/Seizures
Fainting/Nervousness
Heart Disease/Heart Attack
Angina, Pacemaker, Heart Surgery or Irregular beats
Herpes Virus
Asthma/Respiratory problems
Diabetes
Type
Stroke/Convulsions
STD/Venereal Disease
Thyroid Disease
Frequently Tired
Liver Disease
Pregnant?
Of months
Are you Nursing?
Are you taking Birth Control Pills?
Other Medical Condition, past or present
Have you ever been told by your physician that you need PRE MEDICATION (antibiotic) prior to dental treatment?
If yes why
Allergic to
Other's Specify:

Please list all medications you are taking, reason for taking them, frequency and dosage

(Prescription and non‐prescription)

Have you ever been hospitalized for any surgical operation or serious illness?

If yes, please explain
PLEASE SELECT EACH OF THE FOLLOWING: YES OR NO
Had an allergic reaction or Complications to treatment?
Does food catch between your teeth?
Are any of your teeth sensitive to hot, cold, or pressure?
Do your gums bleed?
Do you grind or clench your teeth?
Are there any sores or growths in your mouth?

SLEEP DISORDER OR SLEEP APNEA

Have you been told that you snore?
Have you had or been told that you need sleep study?
Do you have or have you been told you need a CPAP?
If you have a CPAP
How often do you wear it

If you have answered yes to any of the above questions please explain:

NOTE: A change in your health status should be reported to the office at the earliest possible time.
To the best of my knowledge, the foregoing questions have been accurately answered.
Permission to Release Health Information:
I grant the right to the dentist to release health information obtained from me, and information about my dental treatment to third party payers, and/or other health practitioners.

Person completing the form: Signature

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Date:

Witness Signature

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Print Name:
If other than patient, indicate relationship:
Date:
UPDATE:
DATE:
UPDATE:
DATE:
UPDATE:
DATE:

FINANCIAL AGREEMENT

YOU WILL BE GIVEN AN "ESTIMATED" PORTION FOR YOUR DENTAL TREATMENT THAT IS NEEDED, THIS IS ONLY AN ESTIMATE. SOME TEETH MAY HAVE HIDDEN DECAY, OR AFFECTED NERVES, REQUIREING MORE EXTENSIVE DENTAL TREATMENT AND ADDITIONAL COST. PAYMENT IS DUE AT THE TIME OF SERVICE. I UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES. IF FOR SOME REASON MY ACCOUNT SHOULD BECOME DELINQUENT (AFTER 30 DAYS) I AGREE TO PAY THE INTEREST CHARGE OF 18% ON THE UNPAID BALANCE IN THE EVENT OF DEFAULT, I AGREE TO PAY ALL COSTS OF COLLECTION AND ATTORNEY'S FEES.

Signature

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Date:

INSURANCE INFORMATION AND ASSIGNMENT OF BENEFITS

WE WILL ASSIST OUR PATIENTS WHO HAVE INSURANCE BY FlLING THE NECESSARY FORMS. PLEASE BE ADVISED YOUR INSURANCE COMPANY WILL PAY A PERCENTAGE OF OUR FEES AS DETERMINED BY YOUR INSURANCE COMPANY (REFERRED TO AS USUAL, CUSTOMARY, AND REASONABLE FEES). NOT NECESSARILY THE ACTUAL FEE CHARGED BY DR. CASTRO. YOU WILL BE RESPONSIBLE FOR THE DIFFERENCE BETWEEN DR. CASTRO'S FEES AND THE FEE "SUGGESTED" BY YOUR lNSURANCE COMPANY SHOULD THERE BE ONE.

Read and initial:

DR. CASTRO IS ONLY A LISTED PROVIDER FOR SOME OF THE FOLLOWING INSURANCE PLANS: HUMANA, GUARDIAN (AETNA AND UNITED HEALTH), CIGNA (GEHA) AND UNITED CONCORDIA ALLIANCE (SUN LIFE). OTHER INSURANCES WHERE YOU HAVE THE "FREEDOM OF CHOICE" WE WOULD GLADLY SEE YOU AND BILL YOUR INSURANCE AS WITH ANY INSUARNCE PLAN WE CAN NEVER GUARANTEE EXACT PAYMENT. ULTIMATELY YOU ARE RESPONSIBLE FOR ANY UNPAID BALANCE AFTER YOUR INSURANCE PAYMENT HAS BEEN RECEIVED BASED ON OUR FEE, NOT NECESSARILY THE AMOUNT PAID BY YOUR INSURANCE.

Read and initial:

I HEREBY GIVE AUTHORIZATION FOR PAYMENT OF INSURANCE BENEFITS (AS LONG AS I AM A PATIENT OF RECORD) BE MADE DIRECTLY TO DANIEL CASTRO, DDS FOR DENTAL SERVICES RENDEDED. I UNDERSTAND THAT I AM FINANCIAILLY RESPONSIBLE FOR ALL CHARGES WHETHER OR NOT THEY ARE COVERED BY INSURANCE. OUR OFFICE FILES YOUR lNSURANCE AS A COURTESY TO ALL OUR PATIENTS AT NO CHARGE. IF AFTER 30 DAYS WE ARE UNABLE TO COLLECT FROM THEM IT WILL BE YOUR RESPONSIBILITY TO CORRESPOND WITH YOUR INSURANCE COMPANY IN AN ATTEMPT OF PAYMENT. I HEREBY AUTHORlZE MY DENTAL CARE PROVIDER TO RELEASE ALL INFORMATION NECESSARY TO SECURE THE PAYMENT OF BENEFITS.

Signature

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Date:

FAILED APPOINTMENT POLICY

IT IS OUR OFFICE POLICY THAT WE RECEIVE A TWO BUSINESS DAY CANCELLATION NOTICE FOR ANY SCHEDULED DENTAL APPOINTMENT THAT A PATIENT IS UNABLE TO KEEP. THIS WILL ALLOW US TO RESCHEDULE YOUR APPOINTMENT AND LET ANOTHER PATIENT HAVE THE APPOINTMENT TIME ORIGINALLY RESERVED FOR YOU. WE REQUEST THIS COURTESY BECAUSE IT ALLOWS US TO SEE OUR PATIENTS PROMPTLY. IT ALSO HELPS US PROVIDE MORE AFFORDABLE DENTAL CARE FOR ALL OF OUR PATIENTS. IF YOU FAIL AN APPOINTMENT OR ARE ROUTINELY LATE YOU MAY BE DISMISSED FROM OUR DENTAL PRACTICE AN APPOINTMENT IS CONSIDERED FAILED WHEN WE DO NOT RECEIVE A TWO BUSINESS DAY CANCELLATION NOTICE AND THERE MAY BE A $50 CHARGE.

SIGNATURE OF PATIENT OR GUARDIAN

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DATE:

ACKNOWLEDGEMENT OF NOTICE OF PRIVACY PRACTICES

I have read this office's Notice of Privacy Practices attached to clip board.

Date:

Signature

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Print Name:

For Our Office Use Only

Our office attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained for the following reason:

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