Sally A. Abouassaf DDS

9111 FM 723 Suite 400, Richmond, TX, 77406

832-980-9111

Welcome! To assist us in serving you, please complete the following confidential form.
The information provided is important to your dental health

Patient Information

Patient's name:
Social Security#:
Birthdate:
If minor, parents’ names:
Home phone:
Cell phone:
Mailing address:
City:
State:
Zip:
Employer:
Occupation:
Spouse's name:
Spouse's employer:
Whom may we thank for referring you to our office?
Email

Medical Health History

Do you have or have you had any of the following?

Cancer or tumor
Heart Disease
Heart murmur, mitral valve prolapses, heart defect
Rheumatic fever or rheumatic heart disease
Artificial Joint (Knee, Hip… etc.)
High or low blood pressure
Pace maker
Tuberculosis or other lung problems
Kidney disease
Hepatitis or other liver disease
Alcoholism
Blood transfusion
Diabetes
Neurologic condition
Epilepsy, seizures, or fainting spells
Emotional condition
Arthritis
Herpes or cold sores
AIDS or HIV positive
Migraine headaches or frequent headaches
Anemia or blood disorders
Abnormal bleeding after extractions, surgery, or trauma
Hay fever or sinus trouble
Allergies or hives
Asthma
Osteoporosis
Do you smoke or use chewing tobacco?
Have you been diagnosed with sleep apnea?

Are you allergic to, or have you reacted adversely to any of the following?

Latex material
Penicillin or other antibiotics
Local Anesthetics ("Novocain")
Codeine or other narcotics
Sulfa drugs
Aspirin
Barbiturates, sedatives, or sleeping pills
Other:

Are you taking any of the following?

Aspirin
Anticoagulants (blood thinners)
Antibiotics or sulfa drugs
High blood pressure medicine
Antidepressants or tranquilizers
Nitroglycerin
Insulin, Orinase, or other diabetes drug
Cortisone or other steroids
Osteoporosis (bone density) medicine
Bisphosphonates Drugs
Other:

Women:

Expected delivery date:
Name of physician:

Do you have any disease, condition, or a problem not listed above?

Dental Health History


How often do you brush?
How often do you floss?
Chief dental complaint
Last Dental visit

Do you have any jaw symptoms or headaches upon awakening in the morning?
Do you avoid brushing any part of your mouth because of pain?
Does your gum bleed easily?
Does your gum bleed when you floss?
Does your gum feel swollen or tender?
Are you apprehensive about dental treatment?
Have you had problems with previous dental treatment?
Do you gag easily?
Does your jaw make noise so that it bothers you or others?
Do you clench or grind your jaws frequently?
Do your jaws ever feel tired?
Does your jaw get stuck so that you can’t open freely?
Does it hurt when you chew or open wide to take a bite?
Do you have earaches or pain in front of the ears?
Are you unable to open your mouth as far as you want?
Do you have a temporomandibular (jaw) disorder (TMD)?
Have you had a blow to the jaw (trauma)?
Do you wear dentures?
Does food catch between your teeth?
Do you have difficulty in chewing your food?
Do you chew on only one side of your mouth?
Have you ever noticed slow-healing sores I or about your mouth?
Are your teeth sensitive?
Do you take medications or pills for pain or discomfort? (pain relievers, muscle relaxants, antidepressants)

Do you feel twinges of pain when your teeth come in contact with:
Hot foods or liquids?
Cold foods or liquids?
Sours?
Sweets?
Do you have pain in the face, cheeks, jaws, joints, throat, or temples?
Do you take fluoride supplements?
Are you dissatisfied with the appearance of your teeth?
Do you prefer to save your teeth?
Are you interested in whiter teeth?
Are you a habitual gum chewer or pipe smoker?

Signature of patient (or parent):

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Date:

Signature of Dentist:

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Patient Consent Form (HIPAA)

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

  • Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment)
  • Obtaining payment from third party payers (e.g. my insurance company)
  • The day-to-day healthcare operations of your practice

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction.

I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

I understand that an updated version of Family Dental Corner’s Notice of Privacy Practices will be posted on the website and a copy can be provided upon request.

Print Patient Name:
Relationship to Patient:

Signature of Patient /Legal guardian:

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Authorization To Release Dental Information

I request and authorize the above-named doctor or health care provider to release the information specified below to the organization, agency or individual named on this request. I understand that the information to be released includes information regarding the following condition(s):

Patient:

Patient Last Name:
Patient First Name:
Date of Birth:

Release To:

Name/Organization
Phone:
e-mail:
FAX:

INFORMATION REQUESTED:


PURPOSE OR NEED FOR WHICH INFORMATION IS TO BE USED:

Please explain


AUTHORIZATION: I certify that this request has been made voluntarily and that the information given above is accurate to the best of my knowledge. I understand that I may revoke this Authorization at any time, except to the extent that action has already been taken to comply with it.

Patient Name (Print):
Person authorized to sign for patient:

Signature:

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Date:

Financial Policy

Welcome to Family Dental Corner!

We are excited to have you as patient and look forward to offering you and your family the finest dental care available.


Before treatment is provided, we will discuss treatment and financial options. This will help you to fully understand your dental treatment, what to anticipate in fees and allow you time to make the necessary financial arrangements.

Payment is due before services are rendered. For your convenience we accept Cash, Visa, Mastercard and Amex. We also accept “Care Credit” and “Lending Point” which is subject to credit approval. Please ask our friendly staff for more information.


Our fees are based on the quality of materials we use and the time, effort and skills required in performing your needed treatment. We charge what is the usual and customary for our area and will assist you with your benefit eligibility before treatment to help you calculate your costs and maximize your benefits. We will be sensitive to your financial circumstances and do everything possible to help you achieve your perfect oral health.
Dental plan benefits are determined by your employer, not your dentist. Your dental policy is a contract between you and your insurance company; therefore, your specific dental plan and payment is your responsibility. Having a dental plan is not a guarantee of payment; and it often does not cover all the costs involved in treatment. As a courtesy, we will be happy to file your claim for you if you present your current dental card and all required information.

Please be aware that by signing this agreement:

  • You will be expected to pay for services rendered if this office is unable to verify your dental benefits.
  • Any deductible or estimated co-payment amount will be due prior to being taken back for treatment.

If payment for services already rendered has not been paid in full within 45 days, either by you or your insurance company, the remaining balance for your treatment is considered due and must be collected from you prior to any other treatment being rendered. Late fee of $50 will be noted on all accounts if the balance is not paid within 90 days of treatment being rendered.

Separated or divorced parents of minors:

The parent that brings the child in to the dental appointment is responsible for paying the co-payment or full fee. If it is necessary, we are happy to hold credit or debit card information on file from the non-custodial parent. Thank You for your understanding and cooperation.

RESCHEDULING/CANCELLATION POLICY

Our practice is dedicated to quality care and exceptional service. Our doctors and team spend extensive amounts of time preparing for your visit. Broken and missed appointments create scheduling problems for our team as well as other patients. If you find yourself unable to make your appointment or needing to change your appointment, we do require a minimum of 48 hours' notice so that we may make every effort to accommodate other patients. Appointments cancelled or rescheduled with less than a 48-hour notice or appointments not kept will be subject to a $50.00 fee.

I have read and agree to the Financial Policy and the Rescheduling/Cancellation Policy of Family Dental Corner.


Signature of Patient or Responsible Party:

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