Microsoft word - ishsko centre medical forms 2012.docx

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barrack yard I westport I county mayo I ireland I tel: 098-26200 I fax: 098-26202 I www.mercuryfreeentistry.eu | ishskoinfo@ gmail.com | Evelien Van Amerongen (founder, holistic dentist) CONSENT TO TREATMENT
I voluntarily consent to receive dental and complimentary
that all services must be paid for at the time of the visit,
health care services that may include diagnostic procedures,
unless a prior-arranged finance contract is approved. I understand that I will be paying for laboratory tests directly I understand that my GP is ultimately responsible for my to the laboratory, plus any “contact” with the practitioners, general health issues. I understand that communication whether by email, phone, or in-person (charges for “non-local” between the Ishkso Centre and my GP may be necessary, contact will be at the discretion of the centre and will be charged and that any communication will be conducted according to the at prevailing rates – however, in most cases this will not apply centre’s patient guidelines (copy available upon request) for urgent phone contact that lasts less than ten minutes). I agree to allow The Ishsko Centre to charge my credit card for Financial responsibility and assignment of benefits
any outstanding balances that may occur from time to time with prior knowledge to me.
I understand that the diagnostic consultations and therapy fees, as well as the costs for laboratory testing, are available if I also understand that The Ishsko Centre has a 48-hour
cancellation policy and that it is strictly enforced and does
Dental treatment estimates and costs for the centre’s not include weekends or holidays (ie. an appointment that is
personalised wellness programmes are discussed prior to your
scheduled for Monday at 10am must be cancelled no later
next visit to bring clarity to the cost of your wellness than 10am the previous Friday morning in order to avoid a
cancellation charge). Cancellation fees will be based upon the
amount of time that is scheduled for the visit to the centre.
I agree to pay all charges for dental and/or health care
The centre will attempt to contact you as a courtesy prior to
your scheduled appointment time as a reminder. It is therefore I understand that the practitioners at the centre are not important to inform us immediately of any changes of “in-network providers” with any insurance companies, and that the centre operates as a “fee-for-service” centre. I understand I certify that I have read this form and
understand and agree to its contents
Name . n Patient n Legally authorised person (please tick one box) IIIIIIIIIIIIIIIIIII
barrack yard I westport I county mayo I ireland I tel: 098-26200 I fax: 098-26202 I www.mercuryfreeentistry.eu | ishskoinfo@ gmail.com | Evelien Van Amerongen (founder, holistic dentist) Patient in
formation Form

PERSONAL DETAILS
RELATIVE / FRIEND TO CONTACT IN EMERGENCY
Date of birth .
Relationship to patient.
Address .
Address .
Home telephone .
Telephone.
Work telephone.
RESPONSIBLE PERSON (if applicable)
Mobile telephone .
Email Address: .
Marital status:  Single
 Married
Date of birth .
 Divorced
 Widowed
Relationship to patient.
 Female
EMPLOYMENT INFORMATION
Occupation.
 Self Employed
Employed
Address .
 Part-time student
Full-time student
 Other…………………………….
Occupation.
Telephone.
Employer’s name.

Mobile telephone .
Employer’s address.
HOW WERE YOU REFERRED TO ISHSKO?
INSURANCE INFORMATION
(please print name of source)
Name of insured.
By a doctor .
Insurance company .
By a patient .
Group and ID numbers.

By a practitioner .
Address .
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helping you become healthier,
happier . . . and in control
of your life
barrack yard I westport I county mayo I ireland I tel: (00353) (0)98-26200 I fax: (00353) (0)98-26202 I ishsko centre@ gmail.com Dental History Form
Name _______________________ Date __________________ Date of Birth __________________
*Reason For Visit:_________________________________________________________________
When was your last dental visit: _______________________________________________________
How often do you brush your teeth? ____________________________________________________
What texture brush do you use?  Soft  Medium  Hard
Do your gums bleed while brushing?
Do you feel pain to any of your teeth when Are your teeth sensitive to hot, cold, sweet or Have you noticed any loosening of your teeth? Do you have any sores or lumps in or near Is there anything about dental treatment that FOR COMPLETION BY DENTIST
Summary of Dental History:
Summary of Medical History
Medical History Update
Date
Although dental personnel primarily treat areas in and around the mouth, your mouth is 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 that you will be receiving.

Yes No Are you allergic to or have you had reactions to:  Barbiturates, sedatives or sleeping pills Do you have or have you ever had the following:  Rheumatic heart disease / Rheumatic Fever  Heart trouble, heart attack or angina  Hepatitis, jaundice or liver disease  Sinus trouble  Lung or breathing problems  Asthma or hay fever  Hives or skin rash  Persistent cough  Cough that produces blood  Cancer  Sexually transmitted disease  Are you pregnant or think you may be pregnant 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 patients) health. It is my responsibility to inform the dental office
of any changes in my medical status
Signature or patient, parent or guardian______________________________________________
Printed name______________________________________________ Date __________________

Source: http://www.mercuryfreedentistry.eu/downloads/information-pack/ISHSKO%20Centre%20medical%20forms%202012.pdf