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Patient Registration Form

NYC Smile Design

8 East 84th Street,
New York, NY 10028
(212) 452-3344

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Referral( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )
Primary Insurance Details( * mandatory to fill )
Medication List( * mandatory to fill )
Allergy List( * mandatory to fill )
  •  Acrylic
  •  Aspirin
  •  Codeine
  •  Latex
  •  Local anesthetics
  •  Metal
  •  Penicillin
  •  Sulfa drugs
  •  Other
DENTAL & GENERAL HEALTH HISTORY( * mandatory to fill )
  •  Yes
  •  No

If yes:

  •  None
  •  Nightguard
  •  Occusal appliance
  •  Orthotics
  •  I am still wearing a device
SUBSTANCES & CONDITIONS ( * mandatory to fill )

 

Do any of the following conditions apply (mark all that apply):

  •  Daily
  •  Weekly
  •  Occasionally
  •  Daily
  •  Weekly
  •  Occasionally
  •  Day
  •  Week
  •  Month
  •  Day
  •  Week
  •  Month
  •  Daily
  •  Weekly
  •  Occasionally

CONDITIONS: Please mark all that apply

  •  (Men) Prostate disorders
  •  (Women) Pregnant
  •  (Women) Taking birth control
  •  Acid reflux
  •  Antidepressant medications
  •  Arthritis
  •  Artificial Prosthesis/heartvalve/joints
  •  Chemotherapy
  •  Consume grapefruit juice
  •  Contact lenses
  •  Diabetes
  •  Digestive disorders
  •  Emotional problems
  •  Epilepsy or convulsions (seizures)
  •  Family history of snoring or sleep apnea
  •  Glaucoma
  •  Have trouble getting numb before dental treatment
  •  Head or neck injuries
  •  Heart murmur
  •  Heart problems
  •  High or Low blood pressure
  •  History of a stroke
  •  Hives, skin rash, hay fever
  •  Jaundice
  •  Kidney disease
  •  Liver disease
  •  Lumps or swelling in the mouth
  •  Negative reaction to local anesthesia
  •  Often exhausted or fatigued
  •  Often unhappy/depressed
  •  Prolonged bleeding due to cut
  •  Psychiatric treatment
  •  Radiation therapy
  •  Recent changes in your health
  •  Rheumatic fever
  •  Sinus problems
  •  Subject to frequent headache
  •  Rheumatic fever
  •  Sinus problems
  •  Swelling in ankles or feet
  •  Tuberculosis
  •  Tumor or abnormal growth
WRITTEN RESPONSE ( * mandatory to fill )
MULTIPLE CHOICE( * mandatory to fill )
  •  Waiting Room
  •  Dental Chair
  •  When scheduling
  •  When discussing costs
  •  3 Months
  •  4 Months
  •  6 Months
  •  12 Months
  •  Longer
  •  My Dentist
  •  MySelf
  •  Brushing
  •  Flossing
  •  Randomly
  •  I've had periodontal treatment.
  •  Unpleasant taste in mouth
  •  Unpleasant smell in mouth
  •  Orthodontic treatment (braces)
  •  Night guard or occlusal appliance
  •  Am still wearing a device
  •  Orthotic
AREA-SPECIFIC SYMPTOMS ( * mandatory to fill )
If you have any of the following symptoms, please circle yes (Y), no (N) or sometimes (S)

 

HEAD/FACE ACHES

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S

 

JAW

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S

 

NECK

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S

 

EAR

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S

 

EYES

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S

 

THROAT

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S

 

MOUTH

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S

 

NASAL

  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
  •  Y
  •  N
  •  S
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION( * mandatory to fill )

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

 

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our notice accompanies this consent. We encourage you to read it carefully and completely before signing this Consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our notice, at any time by contacting our office at (212)452-3344.

  •  Self
  •  Guradian

I have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and heath care operations.

 

I have received NYC Smile Design's notice of privacy practices

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Sleep Study Form( * mandatory to fill )

SLEEP HISTORY  Mark all that apply to you:

  •  You have had a sleep lab study
  •  You have been diagnosed with a sleep disorder
  •  You are currently using a CPAP machine
  •  You are a CPAP less than five times a week machine
  •  You would prefer an oral appliance

Note: If you have been diagnosed with a sleep disorder, please skip the sections below

PATIENT SLEEPINESS SCALE

Step 1: Answer "Yes" or "No" for the following questions (Y or N). If you answer "Yes", also circle the corresponding points in the column to the right.

Step 2: Total the points you circled in the right column and record the score in the space below.

 

QUESTIONS

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Low
  •  Moderate
  •  High
  •  Severe
  •  0-7
  •  8-11
  •  12-15
  •  16+
  •  B (BMI): Your body mass index is greater than 28
  •  A (Age): You are 50 years old or older
  •  N (Neck): You are a male with a neck circumference greater than 17 inches or a female with a neck circumference greater than 16 inches.
  •  G (Gender): You are a male

The more criteria you mark on the BANG portion, the greater your risk of having moderate to severe Obstructive Sleep Apnea.

 

DROWSINESS How likely are you to doze off or fall asleep in the following situations?

  •  0
  •  1
  •  2
  •  3
  •  0
  •  1
  •  2
  •  3
  •  0
  •  1
  •  2
  •  3
  •  0
  •  1
  •  2
  •  3
  •  0
  •  1
  •  2
  •  3
  •  0
  •  1
  •  2
  •  3
  •  0
  •  1
  •  2
  •  3

The information indicated above is truthful and accurate to the best of my knowledge.

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