DR . MI C H A EL G .

VIENNE , DD S

(o) 318-352-8751; (f) 318-352-9755

129 E 5th St.

Natchitoches LA 71457

Thank you for selecting our dental healthcare team! We strive to provide you with the best possible dental care. To help us meet your entire
dental healthcare needs, please fill out this form completely in ink. Please print legibly to avoid processing errors . If you have questions or
need assistance, please ask us-we will be happy to help.

Todays Date __ __ __ - __ __ - __ __ __ __
__ __

Update __ __ __ - __ __ - __ __

PATIENT INFORMATION (CONFIDENTIAL)

Name: _________________-__________-____________________ Title: ____________ Preferred Name: ____________________
Address:_____________________________________________________City: _____________State: _______ Zip: _____________
Home Phone: __ __ __ - __ __ __ - __ __ __ __
Birth

Cell Phone/Pager: __ __ __ - __ __ __ - __ __ __ __

date: __ __ __ - __ __ - __ __ __ __ Soc. Sec. #: __ __ __- __ __ - __ __ __ E-mail:

___________________________________

Are you an immediate family member of a current patient:

Circle Appropriate Status:

MINOR

YES

NO

SINGLE

If yes, who: _________________________________

MARRIED

DIVORCED

WIDOWED

Employer (or if minor) School ____________________________________ Work Phone __ __ __ - __ __ __ - __ __ __ __

Spouse _____________________________Employer________________________ Work Phone__ __ __ - __ __ __ - __ __ __ __

Circle one or more ways you prefer to be contacted: HOME#

How would you prefer we confirm your appointments: HOME
Were you referred by:

CELL#
WORK

PERSON ___________________________

CELL

WORK#

EMAIL

TEXT

TEXT

EMAIL

MAIL

WEBSITE

PHONEBOOK

Person to Contact in Case of Emergency________________________________ Phone __ __ __ - __ __ __ - __ __ __ __

If Patient is Under 18 yrs of age:

Father:____________________________________

Mother:_____________________________

Address:___________________________________
Address:_____________________________

City :______________________State:___________

City: ___________________State:_________
Birth date __ __ __ - __ __ - __ __ __ __

Birth date __ __ __ - __ __ - __ __ __ __

Soc. Sec. # __ __ __- __ __ - __ __ __

Soc. Sec. # __ __ __- __ __ - __ __ __

Phone: __ __ __ - __ __ __ - __ __ __ __

Phone: __ __ __ - __ __ __ - __ __ __ __

Place of employment:_________________________

Place of employment:_______________________

Work Phone: __ __ __ - __ __ __ - __ __ __ __

Work Phone: __ __ __ - __ __ __ - __ __ __ __
OVER PLEASE
1

DENTAL INSURANCE AND PAYMENT INFORMATION

We have chosen not to be a preferred provider for the insurance with fee
limitations.
Your estimated portion is due at the time of treatment. You are responsible for
ANY balance not paid by your insurance.
If we have to refer your account to a collection agency, you agree to pay
all of the collection costs which are incurred. If we have to refer collection
of the balance to a lawyer, you agree to pay all lawyers fees which we incur
plus all court costs.
Please allow us to copy your dental insurance card(s).
Please provide any information not previously provided
PRIMARY INSURANCE
Name of Insured/Subscriber _____________________________
Insured/Subscriber Soc. Sec. # __ __ __- __ __ - __ __ __

Relationship to Patient________________

Insured/Subscriber Birth date __ __ __ - __ __ - __ __ __ __

Name of Insurance ___________________________ Group ID __________________ Subscriber ID ___________________

Insurance Mailing Address: ____________________________
Name of Employer_______________________________

Insurance Toll Free #: __ __ __ - __ __ __ - __ __ __ __

Work Phone: __ __ __ - __ __ __ - __ __ __ __

Address of Employer__________________________________City______________State_______Zip__________

SECONDARY INSURANCE
Name of Insured/Subscriber _____________________________
Insured/Subscriber Soc. Sec. # __ __ __- __ __ - __ __ __

Relationship to Patient________________

Insured/Subscriber Birth date __ __ __ - __ __ - __ __ __ __

Name of Insurance ___________________________ Group ID __________________ Subscriber ID ___________________

Insurance Mailing Address: ____________________________
Name of Employer_______________________________

Insurance Toll Free #: __ __ __ - __ __ __ - __ __ __ __

Work Phone: __ __ __ - __ __ __ - __ __ __ __

Address of Employer__________________________________City______________State_______Zip__________

I HAVE NO DENTAL INSURANCE BUT HAVE READ AND UNDERSTAND THAT I

AM
REQUIRED TO PAY AT THE TIME SERVICES ARE RENDERED AND
COLLECTIONS COSTS WILL BE MY RESPONSIBILITY:
Sign: ____________________________________ Date: ________________________________________
2

PATIENT MEDICAL HISTORY

Physician_____________________ Office Phone __ __ __ - __ __ __ - __ __ __ __ Date of last exam __ __ __ - __ __ - __ __ __

__

1. Are you allergic

to or have you had any reactions to any drugs?............................ Y . .

If yes, please list_________________________________ ______________________________________________________

2. Are you under any medical treatment now?............ Y . . N

If yes, please explain ______________________________________________________________________________

3. Have you ever been hospitalized for any surgical operation or serious illness?... Y . . N

If yes, please explain ______________________________________________________________________________

4. Are you taking any medication(s), including non-prescription medicine? Y . . N
If yes, what medication(s) are you taking?_______________________________________________________________
5. Do you use tobacco?.......................... Y . . N
6. Your pharmacy_______________________________ Phone __ __ __ - __ __ __ - __ __ __ __
7. Women Only: a) Are you pregnant or may be? .. Y . . N

b) Are you nursing?......... . .. Y . . N

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

High Blood Pressure......Y N
Heart Attack..................

Heart Disease......................Y N
YN

Cardiac Pacemaker............. Y N

Chest Pains..................Y N
Easily Winded.............Y

N
Rheumatic Fever............Y N

Heart Murmur..................Y N

Stroke..........................Y N

Fainting / Seizures.........Y N

Hay Fever / Allergies...........Y N

Tuberculosis................Y N

Asthma...........................Y N

Frequently Tired.............. Y N

Radiation Therapy........ .Y N

Low Blood Pressure..Y N

Anemia.............................Y N

Thyroid Problem....... .Y N

Epilepsy / Convulsions..Y N

Emphysema.......................Y N

Metal Allergies....Y N

Leukemia........................ Y N

Cancer...............................Y N

Sexually Transmitted Disease.Y N

Diabetes........................ ...Y N

Arthritis............................. Y N

Liver Disease...................Y N

Kidney Diseases............Y N

Joint Replacement or ImplantY N

Heart Trouble...............Y N

AIDS or HIV Infection..Y N

Hepatitis / Jaundice...............Y N

Respiratory Problems..... Y N

Stomach Trouble / Ulcers...Y N

Other... ______________________________________________________________
OVER PLEASE
3

PATIENT DENTAL HISTORY

Have you been advised by a physician to premed before your dental appointments? .. Y N
Previous Dentist _________________________ Office Phone __ __ __ - __ __ __ - __ __ __ __ Date of last cleaning _ _ _ -_ _ -_ _ _ _

1.

Did you have x-rays at your last dental exam? . Y.. N

If no, date of last x-rays __ __ __ - __ __ - __ __ __ __ . . .. Date of last FMX __ __ __ - __ __ - __ __ __ __

2.

Have any of your wisdom teeth been extracted? ..Y.. N one two three four

3.

Do you floss regularly? ..Y.. N

4.

Do your gums bleed while brushing/flossing?.............. Y.. N

5.

Have you had: Difficult extractions in the pastY N

6. Do you: Feel pain to any of your teeth?......Y N

Orthodontic work (e.g. braces)?......Y N

Clench or grind your teeth?............... Y

Prolonged bleeding?............... ...Y N

Have any sores/lumps in or near your mouth? Y N

Head, neck, or jaw injuries?........Y N

Bites lips or cheeks frequently?.................. Y

7. Have you experienced any of the following problems

in your jaw:

Clicking?........................................ Y N

8. Are your teeth sensitive to hot and/or cold

liquids and/or food?..

Y N
Pain (joint, ear, side of face)?........Y N
Difficulty in opening or closing?....Y N

9. Would you like for us to contact you for

your next checkup and cleaning appointment?......... Y

N
Authorization and Release
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered.
I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the
diagnosis and a copy of the records of any treatment or examination rendered to my child or me during the period of such Dental care to third party
payers and / or health practitioners. I authorize and request my insurance company to pay directly to the dentists or dental group insurance benefits
otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for
all reasonable collection expenses, including finance charges. I agree to be responsible for payment of all services rendered on my behalf
or my dependents. By supplying my work number, I give permission for the dental office to call me at work.

X_______________________________________________

Signature of patient or parent if minor

MICHAEL G. VIENNE, DDS

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

Section A: Patient Giving Consent

Section B: To the Patient Please read the following statements carefully

Purpose of Consent:
By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment,
payment activities, and healthcare operations.
Notice of Privacy Practices:
You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a
description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your
protected health information, and of other important matters about your protected health information. A copy of our Notice
accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.
We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy
practices, we will issue a revise Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of
your protected health information that we maintain.
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:
The office of: Michael G Vienne, D.D.S. @ 129 E. 5 th Street, Natchitoches, La. 71457
Telephone: (318) 352-8751 Fax: (318) 352-9755
Right to Revoke:
You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the
Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this
Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this
Consent.
I, (PRINT NAME) _______________________________________, have had full opportunity to read and consider the contents of this Consent
form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of
my protected health information to carry out treatment, payment activities and health care operations.

Signature:___________________________________________ Date:____________________

OR

If a personal representative on behalf of the patient signs this Consent, complete the following:
Personal Representatives Name:____________________________________ Relationship:________________________

Revocation Of Consent
I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations.

I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this
written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I have revoked my
Consent.
Signature: ____________________________________________ Date: ____________________________________

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY

PRACTICES
I, (print name) _______________________________, have received and/or read a copy of this offices Notice of Privacy Practices.
_____________________________________ ______________________________________
Signature
Date

You may refuse to sign this acknowledgement

I _________________________________ refuse to sign this acknowledgement due to the following reason:

____________________________________________________________________________________
____________________________________________________________________________________

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.
_________- Communications barriers prohibited obtaining the acknowledgement.
_________- An emergency situation prevented us from obtaining acknowledgement
_________- Other (Please Specify)
____________________________________________________________________
____________________________________________________________________
____________________________________________________________________