Yardley PA Dental Care

301 Oxford Valley Road Suite 401A, Yardley, PA, 19067

Patient Forms
  • (347) 389-4746
  • New York, NY 10038
  • 80 Maiden Ln Suite 702
  • Maiden Lane Dental
  • www.yardleydentalcare.com
  • Acknowledgement of receipt of notice privacy practices

    you may refuse to sign

    i have received/reviewed a copy of this officer's notice of privacy practices.

    Signature of patient /parent or Guardian (if under age 18)

    office use only

    we attempted to obtain written aknowledgement of receipt of our notice of privacy practices. however acknowledgement could not to obtain because:

    communication barriers prohibited obtaining:

    other(specify):

    Dr.Jared Kenwood

    MEDICAL HISTORY

    PATIENT NAME Birth 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.

  • Are you under a physician's care now?

    yes   No

    If yes, please explain:

  • Have you ever been hospitalized or had a major operation?

    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 list:

  • Do you take, or have you taken, Phen-Fen or Redux?

    yes   No
  • Are you on a special diet?

    yes   No
  • Do you use tobacco?

    yes   No
  • Do you use controlled substances?

    yes   No
  • Do you need to pre-medicate?

    yes   No

    If yes, please explain:

  • Are you Pregnant/Trying to get pregnant?

    yes   No
  • Taking oral contraceptives?

    yes   No
  • Nursing?

    yes   No
  • Are you allergic to any of the following?
  • Aspirin
  • Penicillin
  • Codeine
  • Metal
  • Latex
  • Acrylic
  • Local Anesthetics
  • Other Allergies?
  • If yes, please explain:
  • Do you have, or have you had, any of the following?

  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • AIDS/HIV Positive
    yes   No
  • Cortisone Medicine
    yes   No
  • Hemophilia
    yes   No
  • Renal Dialysis
    yes   No
  • Have you ever had any serious illness not listed above?

    yes   No

    yes, please explain:

    Comments:

    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.

    SIGNATURE OF PATIENT, PARENT, or GUARDIAN DATE

    Date: Welcome To Our Office "We Create Gorgeous Smiles" Dr. Jared Kenwood

    M / F

    yes / no

    EXCELLENT GOOD FAIR POOR

    I authorize the release of information, related to my or my family's dental care, to my benefits carrier and assign my/our benefits to your office. I authorize you to sign my signature or write "signature on file" for me in the above matters and forbid my carrier from selectively validating any of my and/or my family members' authorizations to this office. If any one of my "authorizations/signatures" are deemed invalid by my carrier, I revoke all of my authorizations and request that the claim be returned unprocessed. Regardless of my dental benefit(s) plan, I recognize that I am ultimately responsible for dental expenses incurred by myself and/or my family in your office. I have authorized the dentist and his/her staff to diagnose, administer medications and dental treatment necessary for proper dental care. I have been given a copy of your "Office Policies", "Treatment Information" and " Home Care Information" sheet. I have had the opportunity to review them and ask questions. I understand and subscribe to their terms. The information and medical history provided by me on this page is correct to the best of my knowledge and I will not hold my dentist, or any member of his/her staff, responsible for any errors or omissions I have made in completing this form. I have reviewed and accept your HIPPA privacy policies. Unless I notify you in writing, I allow you to use any photographic, video or radiographic images for educational purposes. I acknowledge that payment in full is due pior to or at the time services are rendered unless I have assigned my dental benefits to your office and have preauthorized your office to place any unpaid balances on my credit card of file at your office. Additionally, all cosmetic dentistry must be paid in full prior to treatment. Futhermore, I agree to be charged a time proportionate fee ($45 minimum) for any appointment that I cancel without 24 hour prior notice to your office.

    DENTAL HEALTH and APPEARANCE

    Yes No SOFT MED HARD Yes No hot cold sweet sour none Yes No

  • Do you chew on only one side of your mouth?
    Yes No
    If yes, explain:
  • Do your gums feel tender or swollen?
    Yes No
    Do you usually have many cavities?
    Yes No
  • Do you clench or grind your jaws while sleeping or during the day?
    Yes No
    Do your jaws ever feel tired?
    Yes No
  • We respect your right to choose the level of care that fits your needs. We've found that many adults are unaware that problems even exist. There are rarely symptoms (pain, bleeding) associated with the aging and deterioration of teeth and gums - until it is far too late. According to the ADA, more than 80% of adult Americans have some level of gum disease. With your permission we would like to explain the choices available to achieve long-term health and beauty for your existing natural teeth. Please check all that apply:

  • I desire to keep my own teeth for life, if possible. I want my teeth to look good, feel good, and last for a long time
  • Spreading payments out over time may help me to achieve the excellent results I desire
  • Phasing treatment, by priority, over a few years may make it feasible for me to achieve the excellent results I desire
  • I am interested in a plan for long-term dental health. However, I am currently unable to pursue this, and would appreciate help with emergencies and cleanings for now
  • Although I am not interested in a plan for long-term dental health, I do desire an office who will treat teeth in need of immediate/emergency attention, as well as keep me up to date on cleanings.
  • COSMETIC/ESTHETIC EVALUATION

    Yes No

    What (if any) personal or professional benefit might you gain if you had a gorgeous smile? Do you have any special occasions coming up?

    Yes No . If yes, please check off all that apply:

  • At Yardley Family Dentistry, though our focus is on appearance-related dentistry, we can deliver 99% of your routine dental needs as well. With flexible payment plans as well as phasing treatment over time, you and your family can achieve spectacular long-term results. Thank you so much for the opportunity to be of service.

    Warm regards,

    Jared S. Kenwood, DDS