Save some time before your first appointment at LiveHealthy Dental by printing and filling out our new patient forms beforehand!
You have the option to go to any office below. Please let us know what office you would prefer.
Select Location*: Click to Choose*Central Jacksonville - Narducci Dental Group, P.A.Central Jacksonville - Town Center Dental Group, P.A.Central Jacksonville - Midtown Dental of Jacksonville, P.A.Southside Jacksonville - Southside Dental at Tinseltown, P.A.Callahan - Callahan Family Dentistry, P.A.Jax Beachs - Surfside Dental Center, P.A.Jax Beachs - Surfside Dental Specialist, P.A.West Jacksonville - Marietta Dental Group, P.A.Ocala - Easy Street Dental, P.A.Ocala - Canopy Oak Dental, P.A.The Villages - Colony Dental, P.A.The Villages - East Hamlet Dental, P.A.Orlando - Town Park Dental, P.A.Nocatee/St.Augustine - Beachwalk Dental, P.A.Dunellon - Riverwalk Dental, P.A.Not Sure
If you have any additional questions prior to your appointment, please do not hesitate to call us. We look forward to serving you.
Are you under a physician's care now? YesNo
Have you ever been hospitalized or had a major operation? YesNo
Have you ever had a serious head or neck injury? YesNo
Do you take, or have you taken, Phen-Fen or Redux? YesNo
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates? YesNo
Are you on special diet? YesNo
Do you use tobacco? YesNo
Women: Are you..... Pregnant/Trying to get pregnant?Nursing?Taking oral contraceptives?None of the above
Are you allergic to any of the following? AspirinPenicillinCodeineAcrylicMetalLatexSulfa DrugsLocal AnestheticsNone of above
Any Allergies Not listed above? Please Mention
AIDS/HIV Positive YesNo
Cortisone Medicine YesNo
Hemophilia YesNo
Radiation Treatments YesNo
Alzheimer's Disease YesNo
Diabetes YesNo
Hepatitis A YesNo
Recent Weight Loss YesNo
Anaphylaxis YesNo
Drug Addiction YesNo
Hepatitis B or C YesNo
Renal Dialysis YesNo
Anemia YesNo
Easily Winded YesNo
Herpes YesNo
Rheumatic Fever YesNo
Angina YesNo
Emphysema YesNo
High Blood Pressure YesNo
Rheumatism YesNo
Arthritis/Gout YesNo
Epilepsy or Seizures YesNo
High Cholesterol YesNo
Scarlet Fever YesNo
Artificial Heart Valve YesNo
Excessive Bleeding YesNo
Hives or Rash YesNo
Shingles YesNo
Artificial Joint YesNo
Excessive Thirst YesNo
Hypoglycemia YesNo
Sickle Cell Disease YesNo
Asthma YesNo
Fainting Spells/Dizziness YesNo
Irregular Heartbeat YesNo
Sinus Trouble YesNo
Blood Disease YesNo
Frequent Cough YesNo
Kidney Problems YesNo
Spina Bifida YesNo
Blood Transfusion YesNo
Frequent Diarrhea YesNo
Leukemia YesNo
Stomach/Intestinal Disease YesNo
Breathing Problems YesNo
Frequent Headaches YesNo
Liver Disease YesNo
Stroke YesNo
Bruise Easily YesNo
Genital Herpes YesNo
Low Blood Pressure YesNo
Swelling of Limbs YesNo
Cancer YesNo
Glaucoma YesNo
Lung Disease YesNo
Thyroid Disease YesNo
Chemotherapy YesNo
Hay Fever YesNo
Mitral Valve Prolapse YesNo
Tonsillitis YesNo
Chest Pains YesNo
Heart Attack/Failure YesNo
Osteoporosis YesNo
Tuberculosis YesNo
Cold Sores/Fever Blisters YesNo
Heart Murmur YesNo
Pain in Jaw Joints YesNo
Tumors or Growths YesNo
Congenital Heart Disorder YesNo
Heart Pacemaker YesNo
Parathyroid Disease YesNo
Ulcers YesNo
Convulsions YesNo
Heart Trouble/Disease YesNo
Psychiatric Care YesNo
Venereal Disease YesNo
Have you ever had any serious illness not listed YesNo
If Yes:
Have you ever been hospitlizated or had a major operation? YesNo
Are you taking any medications,pills,or drugs? YesNo
If Yes:Please list the Medicines Name
Do you use controlled sustances? YesNo
Comments:
Signature of Patient,Parents or Guardian:
Date:
Consent to receive dental treatment: I hereby consent and authorize the doctors and staff members to examine, clean and provide dental treatment to my child. I further consent and authorize the taking of dental x-rays, as they may be considered necessary to diagnose and/or treat my child. Minor Drop-Off Consent: In the event I drop off my minor child to receive dental services, I hereby consent the doctors and staff, to clean and provide dental treatment to my child. I have listed a contact person to be reached in case of emergency below:
Name:
Phone:
Relationship: Click to ChooseSelfSpouseChildOther
I acknowledge that payment is due at the time of treatment, unless other arrangements are made. I acknowledge that all financially responsible parties are to be present for all treatment planning and financial estimates. I agree that parents/guardians are responsible for all fees and services rendered for treatment of a minor/child. I accept full financial responsibility for all charges not covered by insurance. In the event my account balance remains unpaid in excess of 90 days, I understand that my account will be turned over to a collections agency. I accept full responsibility for all administrative costs and legal fees associated with the collections process. I agree to reimburse the fees of any collection agency, which may be based on a percentage at a maximum of 54% of the debt, and all costs and expenses, including reasonable attorney’s fees that the dental office incurs in such collection efforts.
I understand that there is a broken appointment policy and I may be charged $40, unless I notify the office within 2 business days of my cancellation.
For your convenience our office takes personal checks. However, I understand a $50 fee will be applied to my account for a bounced check (NSF) and from that point forward, personal checks will no longer be acceptable form of payment.
I, the undersigned, have insurance with and I authorize my insurance company to assign benefits directly to my dental provider, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance within 30 days from the date of service. I hereby authorize the doctor to release all information necessary to secure the payment of benefits. I authorize the use of this signature on all my insurance submissions whether manual or electronic.
By signing below, I hereto irrevocably waive any and all right to trial by jury in any legal proceeding arising out of or related to this agreement or any treatment services provided by offices affiliated with Narducci Dental Group, P.A., its associates, shareholders, and employees. The scope of this waiver is intended to be all-encompassing of any and all disputes that may be filed in any court and that relate to the subject matter of this agreement.
By signing below, I accept the above terms set forth by the dental office and acknowledge full understanding of said terms.
You the patient have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.
It is very important that you follow your dentist’s advice and recommendations regarding medication, pre and post treatment instruction, referrals to other dentists or specialist, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. The patient is an important part of the treatment team. In addition to complying with the instructions given to you by this office, it is important to report any problems or complications you experience so they can be addressed by your dentist.
Certain heart conditions may create a risk of serious or fatal complications. If you (or a minor patient) have a heart condition, advise your dentist immediately so your physician can be consulted if necessary.
If you are a woman on oral birth control medication you must consider the fact that antibiotics might make oral birth control less effective. Please consult with your physician before relying on oral birth control medication if your dentist prescribes, or if you are taking antibiotics.
As with all surgery, there are commonly known risks and potential complications associated with dental treatment. No one can guarantee the success of the recommended treatment, or that you will not experience a complication or less than optimal result. Even though many of these complications are rare, they can and do occur occasionally.
Some of the more commonly known risks and complications of treatment include, but are not limited to the following:
Pain, swelling, and discomfort after treatment.
Infection in need of medication, follow-up procedure or other treatment.
Temporary, or on rare occasion, permanent numbness, pain, tingling or altered sensation of the lip, face, chin, gums, and tongue along with possible loss of taste.
Damage to adjacent teeth, restorations, or gums.
Possible deterioration of your condition which may result in tooth loss.
The need for replacement of restoration, implants or other appliances in the future.
An altered bite in need of adjustment.
Possible injury to the jaw and related structures requiring follow up care and treatment, or consultation by a dental specialist.
Root tip, bone fragment or a piece of dental instrument may be left in your body, and may have to be to be removed at a later time if symptoms developed.
Jaw fracture.
If upper teeth are treated, there is a chance of a sinus infection or opening between the mouth and sinus cavity resulting in infection or the need for future treatment.
Allergic reaction to anesthetic or medication.
Need for follow up treatment, including surgery.
This form is intended to provide you with an overview of potential risks and complications. Please discuss the potential benefits, risks, and complications of recommended treatment with your dentist. Be certain all of your concerns have been addressed to your satisfaction by your dentist before commencing treatment.
Patient Signature*:
date*:
Print Patient Name*:
Minor (Patient Signature)*:
Date*:
Parent/Legal Guardian*:
I understand that the novel Coronavirus (COVID-19) has been declared a global pandemic by the World Health Organization (WHO). I further understand that COVID-19 is extremely contagious and may be contracted from various sources. I understand COVID-19 has a long incubation period during which carriers of the virus may not show symptoms and still be contagious. I understand that I am the decision maker for my health care. Part of this office’s role is to provide me with information to assist me in making informed choices. This process is often referred to as “informed consent” and involves my understanding and agreement regarding recommended care, and the benefits and risks associated with the provision of health care during a pandemic. Given the current limitations of COVID-19 virus testing, I understand determining who is infected with COVID-19 is exceptionally difficult.
1) I understand my treatment may create circumstances, such as the discharge of respiratory droplets or person-to-person contact, in which COVID-19 can be transmitted.
2) I understand due to the frequency of appointments with patients, the attributes of the virus, and the characteristics of procedures, I may have an elevated risk of contracting COVID-19 simply by being in a health care office.
3) I confirm I am not experiencing any of the following symptoms of COVID-19 that are listed below: *Fever *Shortness of Breath *Dry Cough *Runny Nose *Sore Throat *Loss of Taste or Smell
4) I am informed that you and your staff have implemented preventative measures intended to reduce the spread of COVID-19. However, given the nature of the virus, I understand there may be an inherent risk of becoming infected with COVID-19 by proceeding with this treatment. I hereby acknowledge and assume the risk of becoming infected with COVID-19 through this elective treatment and give my express permission to you and the staff at your offices to proceed with providing care.
I KNOWINGLY AND WILLINGLY CONSENT TO THE TREATMENT WITH THE FULL UNDERSTANDING AND DISCLOSURE OF THE RISKS ASSOCIATED WITH RECEIVING CARE DURING THE COVID-19 PANDEMIC. I CONFIRM ALL OF MY QUESTIONS WERE ANSWERED TO MY SATISFACTION. I HAVE READ, OR HAVE HAD READ TO ME, THE ABOVE COVID-19 RISK INFORMED CONSENT TO TREAT. I APPRECIATE THAT IT IS NOT POSSIBLE TO CONSIDER EVERY POSSIBLE COMPLICATION TO CARE.
I HAVE ALSO HAD AN OPPORTUNITY TO ASK QUESTIONS ABOUT ITS CONTENT, AND BY SIGNING BELOW, I AGREE WITH THE CURRENT OR FUTURE RECOMMENDATION TO RECEIVE CARE AS IS DEEMED APPROPRIATE FOR MY CIRCUMSTANCE. I INTEND THIS CONSENT TO COVER THE ENTIRE COURSE OF CARE FROM ALL PROVIDERS IN THIS OFFICE FOR MY PRESENT CONDITION AND FOR ANY FUTURE CONDITION(S) FOR WHICH I SEEK CARE FROM THIS OFFICE.
Print Patient’s (or Legal Guardian’s) Name/Relationship
Patient’s (or Legal Guardian’s) Signature
I, , hereby acknowledge that I have received and reviewed a copy of Narducci Dental Group, P.A., and affiliated dental practices HIPAA Notice of Privacy Practices.
I understand that Narducci Dental Group, P.A., and affiliated dental practices HIPAA Notice of Privacy Practices may change periodically and that I am entitled to receive a copy of Narducci Dental Group, P.A., and affiliated dental practices revised HIPAA Notice of Privacy Practices upon request.
I understand that, if I have questions about Narducci Dental Group, P.A., and affiliated dental practices HIPAA Notice of Privacy Practices, I may contact Narducci Dental Group, P.A., at (904) 998-7000.
I understand that it is my right to refuse to sign this Acknowledgement should I so choose, and that Narducci Dental Group, P.A. and affiliated dental practices will not refuse treatment to me if I refuse to sign this Acknowledgement.
I further understand that I may contact the Secretary of the U.S. Department of Health and Human Services should I have concerns regarding Narducci Dental Group, P.A. and affiliated dental practices privacy policies and procedures. For information on how to contact the U.S. Department of Health and Human Services, please ask Narducci Dental Group, P.A., at (904) 998-7000, noted above, for assistance.
Signature of Patient:
Bisphosphonates are a type of drug given to millions of Americans to treat osteoporosis or as part of cancer treatment, namely for breast cancer, lung cancer, prostate cancer, multiple myloma, Paget’s disease of the bone, alveolar necrosis of the bone or postmenopausal osteoporosis. They are sometimes given orally and other times are given through people’s veins. Some of the common names include but are not limited to:
Actonel (Risedronate)
Bonefos (Clodronate)
Fosamax (Alendronate)
Fosamaz Plus D (Alendronate)
Aredia (Pamidronate)
Didronel (Etidronate)
Boniva (Ibandronate)
Ostac
Skelid (Tiludronate)
Zometa (Zolendronic Acid)
Pamidronate
In rare instances, some people on these drugs have developed a condition called Osteonecrosis of the jaw, which results in severe damage to or loss of the jaw bone. Symptoms include but are not limited to pain, swelling or infection of the gums or jaw, gums that are not healing, loose teeth, numbness or a heavy feeling in the jaw, drainage and exposed bone. There is no proven treatment to fix this problem.
Accordingly, patients on these drugs should know the risks, benefits, and alternatives of invasive dental procedures. If a patient is on Bisphosphonates, your dentists, follows special procedures to promote the safety of the patient. It is very important that you let the dentist know whether you are taking any medications, particularly a Bisphosphonates drug, or if you have ever taken a Bisphosphonate drug. If you are not sure if the drugs you are taking are Bisphosphonates, ask the dentist. You have a duty and responsibility to tell the dentist all the drugs that you take.
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I hereby disclose that:
YES, I AM on a Bisphosphonate or have taken one in the past. It is called: I have taken this medication for: (Amount of time) NO, I am NOT on any Bisphosphonates and have never taken or been given Bisphosphonates.
Print Name:
Signature:
I UNDERSTAND THAT THE COMPLICATION STATED ABOVE CAN HAPPEN WITH SURGICAL AND NON-SURGICAL TREATMENT, AS WELL AS, SPONTANEOUSLY AND AGREE TO PROCEED WITH THE RECOMMENDED TREATMENT:
We have the ability to send text and email messages to your provided cell phone number to receive account information such as appointment reminders, appointment openings, account updates, marketing specials, opportunities, and other alerts
Please indicate below whether you would like to receive text and email confirmation,reminders,newsletters,specials, and other updates. Text message charges from your cell phone provider may apply.
By signing below, I wish to enroll in the text message and email alert communication explained above
Cell Phone:
Email Address:
You can withdraw your consent at any time by calling the office. You are resposible providing updates to your cell phone and email information
It is important to note that text communication is not always secure. Text messages can be intercepted and for this reason, we do not communicate personal health information through this method.
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