Patient Information Additional Comments: Primary Insurance Information Responsible Party (if someone other than the patient) ID: First Name: Policy Holder Responsible Party Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder Section 2 Full Time Part Time Retired Section 3 Address 2: State / Zip: Sex: Marital Status: Married Single Divorced Separated Widowed E-mail: I would like to receive correspondences via e-mail. Address: City: Male Female Birth Date: Full Time Part Time Employment Status: Student Status: Medicaid ID: Pref. Dentist: Employer ID: Pref. Pharmacy: Carrier ID: Pref. Hyg.: Name of Insured: Self Spouse Child Other Address 2: First Name: Address: Home Phone: Birth Date: Drivers Lic: Soc Sec: Work Phone: Ext: Cellular: City, State, Zip: Pager: Middle Initial: Last Name: Insured Soc. Sec: Insured Birth Date: Secondary Insurance Information Name of Insured: Self Spouse Child Other Rem. Deduct: .00 Employer: Address: Address 2: City,State,Zip: Ins. Company: Address: Address 2: City,State,Zip: Rem. Benefits: .00 Insured Soc. Sec: Insured Birth Date: Employer: Address: Address 2: City,State,Zip: Ins. Company: Address: Address 2: City,State,Zip: Rem. Benefits: .00 Rem. Deduct: .00 Soc. Sec: Age: Drivers Lic: Chart ID: Home Phone: Work Phone: Pager: Ext: Cellular: Last Name: Middle Initial: Patient Is: Relationship to Insured: Relationship to Insured: Preferred Name: Patient Registration
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Patient Registration · 2020-04-24 · 3. The susceptibility of your teeth and/or internal colors to the whiten ing agent. 4. Habits you have that discolor teeth, such as smoking
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Transcript
TIME 10:51 AM
PATIENT REGISTRATION
DATE 6/22/2012
Patient Information
Additional Comments:
Primary Insurance Information
Responsible Party (if someone other than the patient)
ID:
First Name:
Policy HolderResponsible Party
Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder
Section 2
Full Time Part Time Retired
Section 3
Address 2:
State / Zip:
Sex: Marital Status: Married Single Divorced Separated Widowed
E-mail: I would like to receive correspondences via e-mail.
Address:
City:
MaleOther
Female
Birth Date:
Full Time Part Time
Employment Status:
Student Status:
Medicaid ID: Pref. Dentist:
Employer ID: Pref. Pharmacy:
Carrier ID: Pref. Hyg.:
Name of Insured: Self Spouse Child Other
First Name:
Address 2:
First Name:
Address:
Home Phone:
Birth Date: Drivers Lic:Soc Sec:
Work Phone: Ext: Cellular:
City, State, Zip: Pager:
Last Name: Middle Initial:Last Name:
Insured Soc. Sec: Insured Birth Date:
Secondary Insurance Information
Name of Insured: Self Spouse Child Other
Rem. Deduct: .00
Employer:
Address:
Address 2:
City,State,Zip:
Ins. Company:
Address:
Address 2:
City,State,Zip:
Rem. Benefits: .00
Insured Soc. Sec: Insured Birth Date:
Employer:
Address:
Address 2:
City,State,Zip:
Ins. Company:
Address:
Address 2:
City,State,Zip:
Rem. Benefits: .00 Rem. Deduct: .00
Soc. Sec:Age: Drivers Lic:
Chart ID:
Home Phone: Work Phone:
Pager:
Ext: Cellular:
Last Name: Middle Initial:
Patient Is:
Relationship to Insured:
Relationship to Insured:
Preferred Name:
Patient Registration
TIME 10:39 AM DATE 6/22/2012
MEDICAL HISTORY
PATIENT NAME _______________________________________________ Birth Date _____________________________________
Johnson Dental
Do you have, or have you had, any of the following?
Yes No
Are you allergic to any of the following?
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can bedangerous 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 ______________________
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
following questions.have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the
If yes, please explain:Are you under a physician's care now? Yes No
Have you ever had a serious head or neck injury?Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Yes No If yes, please explain:Yes No If yes, please explain:Yes No If yes, please explain:
_____Emergency situation prevented us from obtaining acknowledgement.
_____Other ***Scanned Copy Serves as an Original***
Expectations
Whitening is effective for most patients and has been proven to be safe when done properly. The length of treatment ranges from a minimum of 2 weeks up to 4-8 weeks or more for patients with darker teeth. The degree of whitening you obtain during the procedure is dependent on four factors:
1. The length of time in each 24-hour period the tray is worn (a session). 2. The number of sessions the tray is worn. 3. The susceptibility of your teeth and/or internal colors to the whitening agent. 4. Habits you have that discolor teeth, such as smoking or the consumption of coffee, tea,
tomato sauce, red wine, etc. Crowns, bridges, veneers, partial dentures, and white fillings will not whiten with this treatment.
Directions for whitening your teeth
1. Before inserting trays, brush and floss your teeth thoroughly. 2. Ensure that your trays are dry. Express a small amount of whitening gel into the deepest,
outermost portions of the trays. A large amount is not needed. 3. Seat the trays completely onto the teeth. 4. Gently press the tray with a clean finger to adapt the soft tray material against the teeth
on the inside (tongue) and the outside (lip) edges of the tooth/gum area. Use caution since pressing too firmly will express too much gel out of the tray.
5. Wipe off excess gel with a clean finger or cotton swab. 6. Do not disturb the trays when wearing by lifting with tongue, fingers, etc. Take care not
to bite with pressure on the tray. This may cause excess solution to sit on the gum tissue, which can result in a tissue burn.
7. It is best to wear the trays overnight while sleeping (8-10 hours). This can be modified if you are experiencing more pain than you can handle or if you cannot tolerate wearing the trays while sleeping. Trays can be worn for 4 hours during the day OR can be worn every other night or day. If you do this, your treatment time will be lengthened, but you can still achieve the same results.
8. Remove the trays after wearing for the appropriate amount of time. Brush teeth thoroughly with toothpaste. Rinse twice; do not swallow rinsed gel. Brush tray gently with soft brush and rinse with cool water. Store trays in their case when not in use, but be sure they dry thoroughly so they are ready to be used for the next session.
9. After you are done whitening, you will need to touch up your whitening periodically (usually 1-3 times per year, depending on your eating habits). By touching up, you will be able to maintain your beautiful, white smile for years to come.
Possible side effects
Many times patients will experience increased sensitivity to cold during treatment. Some patients have reported temporary discomfort during whitening, such as gum and/or tooth sensitivity, tongue and lip soreness, or moderate, continuous teeth pain. Acidic, citric foods may increase sensitivity temporarily. Tips to reduce discomfort include:
1. Prevident (a high-fluoride prescription toothpaste sold at Johnson Dental) can be used
daily for at least 2 weeks before whitening is started, and also throughout the duration of the whitening process.
2. Ibuprofen or Tylenol can be used to reduce acute pain that can be associated with whitening.
3. If sensitivity becomes too uncomfortable, or if the trays cannot be tolerated at night, trays can be worn for 4 hours during the day. This will lengthen the total whitening time, but you will get the same great results.
If any of these symptoms occur and the above tips do not work for you and your pain is more than mild or persistent, or if you have any questions or concerns, call us at 507.645.9669. These side effects almost always resolve in 1-3 days after interruption or completion of treatment.
Precautions
1. Avoid dark foods or drinks that may restain your teeth for 24 hours after whitening. Examples of foods that can stain are coffee, tea, red wine, tomato sauce, tobacco, and dark berries.
2. Do not eat with your whitening trays in your mouth. 3. Keep and store the whitening agent out of heat or direct sunlight at all times to keep the
whitening agent from chemically breaking down. Store unopened tubes in the refrigerator, but keep the tube you are using at room temperature to help decrease sensitivity.
4. Keep your whitening solution away from small children and pets. 5. NEVER use any household or commercial whitening agents in your mouth!
Restorative procedures (fillings and crowns) can be scheduled 2 weeks after the last session of whitening is completed. This is necessary for shade normalization and optimal bonding.
All instructions and information are also available on our website Johnson-Dental.com