The Six Important Things We All Need to Know



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Jason D. Roe, DDS, PLLC

The Six Important Things We All Need to Know....
1. The following are infections and contagious. They usually don’t hurt.

2. Tooth pain at times will come and go away completely.  When pain disappears, it gives

a false sense of security that the tooth is normal, and upon return it will intensify each

time.  The first sign of discomfort is the right time to contact your dentist.  Waiting

could result in irreversible damage.

3. Our teeth can shift within a 24 hour period.  This is one of contributing reasons night

guards won’t fit when not worn each night.

4. Most over the counter mouth rinses can contain as high as 20% alcohol, leading to dry gum

tissue causing pain and dissolving the bonding in fillings, onlays, inlay and veneers. 

5. Do you know what is lurking beneath your gums?



  • At home, we are only able to clean up to the first 3mm of gum tissue by brushing, flossing and water irrigators (WaterPik, etc). 

  • Periodontal pockets of 3mm or less often indicate healthy gum tissue.  Periodontal pockets of 4mm and deeper can indicate periodontal involvement and require a dental hygienist to access.

  • Bacteria in periodontal pockets of 4mm and deeper are able to re-infect sooner than every 3 months following dental cleanings.  

  • Periodontal pockets left untreated may progress to bone loss, a periodontal abscess, and possibly heart disease.

  • While pregnant, women should have their teeth cleaned every 3 months.

6. Wearing dentures does not eliminate the future need to see your dentist.  Annual

examinations are necessary for oral cancer screenings, to check your bite, and to check

for mold and yeast that will infect and irritate your gum tissue. We look for cracks or

fractures early on and we check for shrinkage in your bone and tissue, which can

contribute to uncomfortable sore spots.

MEDICAL HISTORY
Patient's Name ____ Birth Date ____/____/____ SS#____ - ____ - ____
The following information is essential for this office to provide dental care in a manner that is compatible with your general health. Your cooperation in providing accurate information is necessary to meet your dental needs safely and efficiently.

INCORRECT INFORMATION CAN BE DANGEROUS TO YOUR HEALTH

**Write the answer to each question in the space provided**

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Name of Medical Physician: __________________________ Phone# ( ___ ) ____ - ______

Address_______________________________________________ Date of Last Visit ____ / ____ / ____


Reason for Last Visit_____________________________________________________________________


  1. Are you currently under the care of a Physician?………………………………………………………….( )Yes ( )No

If “YES”, for what reason or condition?________________________________


  1. Are you currently taking any medications?………………………………………..…………..…( )Yes ( )No If “YES”, please list what medications, and for what reason or condition on a separate page.

________________________________________________________________________
HAVE YOU EVER HAD TREATMENT FOR:

If yes, please circle the condition
3. Rheumatic Fever, Rheumatic Heart Disease, Heart Murmur or Congenital Heart Disease?…( ) Yes ( ) No

4. Heart trouble, heart attack, Angina, heart surgery, a pacemaker, or irregular beats?….……( ) Yes ( ) No

5. Have you ever taken Phen Phen? If yes, give dates…………………….……….…………….……… ( ) Yes ( ) No
6. Abnormal blood pressure, excessive bleeding, or Anemia?……………………………………………( ) Yes ( ) No
7. Breathing problems, Asthma, Tuberculosis, or Hay Fever?…………………………………………..( ) Yes ( ) No
8. Cancer, radiation treatments, or chemotherapy? If yes, please explain…………………………( ) Yes ( ) No
9. Diabetes?………………………………………………………………………………………………………………..( ) Yes ( ) No
10. Hepatitis, Jaundice, or Liver Disease?…………………………………………………………………………( ) Yes ( ) No
11. Kidney problems or Renal Dialysis?……………………………………………………………………………..( ) Yes ( ) No
12. AIDS?……………………………………………………………………………………………………………………..( ) Yes ( ) No
13. Arthritis or Rheumatism?……………………………………………………………………………………………( ) Yes ( ) No


  1. Allergic reactions to medications? If yes, please explain.…………….…………………………………( ) Yes ( ) No

15. Have taken steroids in the last year?…………………………………………………………………………( ) Yes ( ) No


16. Have you ever had surgery?……………………………………………………………………………………..( ) Yes ( ) No



If yes, please explain______________________________________________________
17. Have you ever had a serious injury to your head or neck?………………………………………….( ) Yes ( ) No

If yes, explain.__________________________________________________________
18. Do you smoke? If yes, how many packs a day?..…………………………………………………( ) Yes ( ) No
19. Have you consulted or been treated by a psychiatrist, psychologist, or counselor?……….( ) Yes ( ) No

If yes, please explain.____________________________________________________
20. Are there any other problems about your health of which you are aware?…………………..( ) Yes ( ) No

If “Yes”, please explain.___________________________________________________


  1. FOR WOMEN: Are you pregnant? If yes, what is your due date? ___ / ___ / ___ ……… ( ) Yes ( ) No




  1. Do you have headaches? If yes, how often?..........................................................( ) Yes ( ) No




  1. Do you or your partner snore or gasp for air during sleep?.….…………………………………… ( ) Yes ( ) No




  1. Do you have artificial joints or valves? If yes, please explain…………….……….……………...( ) Yes ( ) No


Emergency Contact Information: Contact #1 Name :_______________________________ Phone # ( ____ )______ - ______

Relationship to Patient: __________________

Contact #2 Name :_______________________________ Phone # ( ____ )______ - ______

Relationship to Patient: __________________

Blood Pressure taken in office:__________________

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NOTE: A change in your health status should be reported to the office at the earliest possible time.

To the best of my knowledge, all the questions on this form have been accurately answered.

I grant the right to the dentist to release health information obtained from me, and information about my dental treatment to third party payers, and/or other health practitioners.
__________________________ ____________________

Signature of responsible party Date Form Signed & Completed

____________________________________ _______________________

Print Name Relationship, if other than patient
I give the dentist permission to use my photographs for educational and promotional

purposes.
____________________________ _____________________

Signature Date

______________________________ _______________________

Signature of Dr. Date


Jason D. Roe, DDS, FACP

18383 Preston Rd, Suite 207

Dallas, TX 75252

(972) 931-1777
REGISTRATION
Last Name____________________________________ First ____________________________ MI _______
Nickname______________________________ Birth Date _____ / _____ / ________ Age _____ Sex _M / F__
Social Security # ________ / ________ / ________ (if required by your insurance company)
Home Address _________________________________________________________________________________
City ______________________________ State ________________ Zip _________
Home Phone: ( ____ ) _____ - ______ Work Phone: ( ____ ) _____ - ______ Cell: ( ____ ) _____ - ______
E-Mail _______________________________________ May we e-mail messages to you? ___________________
Employer ______________________ Address ______________________________ Occupation ______________
Who may we thank of referring you to our practice: __________________________________________________
Spouse’s Name ________________________________________________________________________________

ACCOUNT INFORMATION



Person Responsible for Account (If different than patient):
Last Name ___________________________________ First ________________________________ MI ________
Relationship to Patient _____________________ Birth Date _____ / _____ / _____ Age ________ Sex _M / F__
Home Address ____________________________________ City_____________ State ________ Zip___________
Home Phone: ( ____ ) _____ - ______ Work Phone: ( ____ ) ______ - ______ Cell: ( ____ ) ______ - ______
Social Security # ________ / ________ / ________ (if required by insurance company)
Employer _____________________________________________ Occupation _____________________________
Employer’s Address ____________________________________________________________________________


DENTAL INSURANCE INFORMATION

Insurance Company ______________________________ Phone # (_____ ) ______ - ______

Insured Name: _______________________ Self / Spouse / Parent

Insured SS# and ID # ______ - ______ - ______ Insured DOB _____ / _____ /_____

Employer Group Name ___________________________ Group # ____________________

I authorize the Dentist to perform diagnostic procedures and treatment as may be necessary for proper dental care. I also authorize release of any information concerning my (or my child’s) health care, medical history, advice and treatment to another dentist of if applicable, an insurance company. Since appointment times are reserved exclusively for me, I understand that charges will occur if I give less than 24 hours notice of an appointment change or cancellation.

Signature _____________________________________________ Date ___________________________________

Jason D. Roe, DDS, FACP

ACKNOWLEDGEMENT OF RECEIPT OF

NOTICE OF PRIVACY PRACTICES
*You May Refuse To Sign This Acknowledgement
I, _____________________________, have received a copy of this office’s Notice of Privacy Practices.
I also authorize Dr. Jason Roe and his staff to discuss my medical care with the following individual(s) listed below. If there are any limitations on what we may discuss with these individuals, it must be received in writing and will be added to your file. This will remain in force unless revoked in writing.
Name Relationship

_____________________________________ ______________________

_____________________________________ ______________________

_____________________________________ ______________________

_____________________________________ ______________________

_____________________________________ ______________________


_____________________________________ ______________________

Signature Date



For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice Of Privacy Practices, but acknowledgement could not be obtained because:

□ Individual refused to sign

□ Communication barriers prohibited obtaining the acknowledgement

□ An emergency situation prevented us from obtaining acknowledgement

□ Other (Please specify):


Jason D. Roe, DDS, FACP
Practice Policies
We are honored that you have chosen us to provide your dental care. We are here to help you and below are some general guidelines for our office
General


  • Patients are seen by appointment only.

  • Office hours are Monday through Thursday 8:00 – 4:00, and we are closed for lunch from 12:00 – 1:00.

  • Cancellations within 24 hours of your appointment will be charged a fee of $100. If you need to cancel or reschedule your appointment, please verbally notify us at least 48 business hours in advance. We do not accept changes to the schedule on our voicemail system.

  • “No Show” appointments will be charged your appointment fee in full starting with a minimum of $300.

  • After the first “No Show” appointment, all other appointments will need to be pre-paid in full at the time the appointment is scheduled.

  • If a patient has three (3) last-minute cancellations or missed appointments in a twelve month period of time, we reserve the right to terminate the patient/doctor relationship.

  • As a courtesy to you, all appointments will receive a 2 week reminder from our office. At that time, we ask that you confirm the appointment, and update our office of any changes in your contact information, or insurance information.


Payments

  • We accept American Express, Master Card, Visa and Discover

  • For your convenience, our office offers third party financing through Care Credit Corporation and 12 month No Interest is available.

  • Payments for services are to be paid at the time services are rendered.


Insurance

  • To better assist you, we do require all insurance information and verification 48 hours prior to your appointment time.

  • As we are not contracted with dental insurance companies, your insurance will reimburse you directly for services rendered in our office. We will file claims as a courtesy to you, however, all fees are ultimately the responsibility of the patient regardless of insurance.

__________________________________ _____________________

Patient Name Date


__________________________________

Patient Signature


Jason D. Roe, DDS, FACP

New Patient Questionnaire
Patient Name: _______________________________ Date: _________________________
Please tell us the type of oral hygiene products you use at home:

Electric Toothbrush: ______________________________

Toothpaste:______________________________________

Mouth Rinse: ____________________________________


Please check all the procedures below that you are interested in?

¨ Check up, Cleaning, X-Rays ¨ Second Opinion ¨ Invisible Braces

¨ Teeth Whitening ¨ Porcelain Veneers ¨ Tooth Colored Fillings ¨ Dental Implants

¨ Sedation Dentistry ¨ Cosmetic Consultation ¨ Other ____________________


How much do you know about these procedures you are interested in?

¨ I’ve just begun researching the procedure

¨ I’ve been researching for the last few months

¨ I know someone who has had the procedure already

¨ I am ready to begin treatment
How soon are you planning to begin treatment?

¨ I am ready to begin

¨ Within 1-3 months

¨ Within 3-6 months

¨ After 6 months
During sleep do you:

¨ Snore


¨ Choke or gasp for air

¨ Grind your teeth



¨ Do you wake up refreshed Yes / No


Briefly explain your current dental situation and what you would like to improve.

________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




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