Patient Forms

Welcome to Our Dental Practice!

At Powers Family Dental Care, your comfort, well-being, and oral health are our top priorities. We understand that your time is valuable, and we strive to make the process of giving us your information as convenient as possible.

To cater to everyone's individual preferences, we offer two options for presenting your patient forms:

Online Filling: You can complete the forms digitally. Simply click the Start button below to access our easy-to-use online form. Filling it out online helps us streamline your visit, allowing for a more efficient and time-saving experience.
Print and Fill: If you prefer a paper-based method or are not comfortable with digital forms, we’ve got you covered. You can choose to print the forms by clicking here. After printing, you can fill out the form at your leisure and bring it to your appointment, giving you the flexibility you need.

Why do we ask for this information? Your dental health is closely interrelated with your overall well-being, and our team of skilled professionals strives to provide you with the best possible care. By gathering important details about you, we ensure we comprehensively understand your unique needs and circumstances.

Rest assured, all the information you provide is strictly confidential and securely stored in compliance with privacy regulations. By completing this form, you help us tailor our services specifically to your requirements, ensuring a personalized and comfortable dental experience.

Should you have any questions or concerns about either method of form submission, our friendly team is always here to assist you.

Thank you for choosing Powers Family Dental Care. We are excited to welcome you to our dental family and look forward to providing you exceptional care, comfort, and a captivating smile!

Patient Information

Emergency Contact

Dental Insurance

Dental History

Medical History

Consent

Privacy Practices & Submission

General Information

Last Name

First Name

M.I.

Date Of Birth

Sex

SSN(US) / SIN(CAN)

Home Phone #

Cell Phone #

E-Mail

Street Address

Apt #

City

State

Zip/Postal Code

Prefer To Be Called

Are You Employed

Yes

Marital Status

Employer Information

Employer Name

Occupation

Phone #

Street Address

Apt #

City

State

Zip/Postal Code

Spouse Information

Last Name

First Name

M.I.

Employer Name

Occupation

Phone #

Street Address

Apt #

City

State

Zip/Postal Code

Misc. Information

Other Family Members That Are Patients Here

Who Can We Thank For Referring You To Our Office

Emergency Contact Information
Person We May Contact In Case Of An Emergency (Other Than Your Family Home)

Full Name

Relationship

Home Phone #

Work Phone #

Cell Phone #

Dental Insurance

Do You Have Dental Insurance

Yes

Insurance Company Name

Phone #

Street Address

City

State

Zip/Postal Code

Subscriber's Name

Patient's Relationship To Subscriber

Subscriber' Birthday

SSN(US) / SIN(CAN)

Group/Program Number

Subscriber ID#

Employer

Employer Address

Do You Have Secondary Coverage

Yes

Insurance Company Name

Phone #

Street Address

City

State

Zip/Postal Code

Subscriber's Name

Patient's Relationship To Subscriber

Subscriber' Birthday

SSN(US) / SIN(CAN)

Group/Program Number

Subscriber ID#

Employer

Employer Address

Medical History

Name Of Physician

Physician Specialty

Latest Physical Exam Date

Purpose Of Exam

Current Health Condition

Do You Have Or Have You Ever Had

hospitalization for illness or injury

Yes No

heart problems, or cardiac stent within the last six months

Yes No

history of infective endocarditis

Yes No

artificial heart valve, repaired heart defect (PFO)

Yes No

pacemaker or implantable defibrillator

Yes No

orthopedic or soft tissue implant (e.g joint replacement, breast implant)

Yes No

heart murmur, rheumatic or scarlet fever

Yes No

high or low blood pressure

Yes No

a stroke (taking blood thinners)

Yes No

anemia or other blood disorder

Yes No

prolonged bleeding due to a slight cut (or INR > 3.5)

Yes No

pneumonia, emphysema, shortness of breath, sarcoidosis

Yes No

chronic ear infections, tuberculosis, measles, chicken pox

Yes No

breathing problems (e.g. asthma, stuffy nose, sinus congestion)

Yes No

sleep problems (e.g. sleep apnea, snoring, insomnia, restless sleep, bedwetting)

Yes No

kidney disease

Yes No

liver disease or jaundice

Yes No

vertigo (e.g. ”the room is spinning”)

Yes No

thyroid, parathyroid disease, or calcium deficiency

Yes No

hormone deficiency or imbalance (e.g. poly cystic ovarian syndrome)

Yes No

high cholesterol or taking statin drugs

Yes No

diabetes

Yes No

stomach or duodenal ulcer

Yes No

digestive or eating disorders (e.g. celiac disease, gastric reflux, bulimia,anorexia)

Yes No

osteoporosis/osteopenia or ever taken anti-resorptive medications (e.g. bisphosphonates)

Yes No

arthritis or gout

Yes No

autoimmune disease (e.g. rheumatoid arthritis, lupus, scleroderma)

Yes No

glaucoma

Yes No

contact lenses

Yes No

head or neck injuries

Yes No

epilepsy, convulsions (seizures)

Yes No

neurologic disorders (ADD/ADHD, prion disease)

Yes No

viral infections and cold sores

Yes No

any lumps or swelling in the mouth

Yes No

hives, skin rash, hay fever

Yes No

STI/STD/HPV

Yes No

hepatitis

Yes No

HIV/AIDS

Yes No

tumor, abnormal growth

Yes No

radiation therapy

Yes No

chemotherapy, immunosuppressive medication

Yes No

emotional difficulties

Yes No

psychiatric treatment or antidepressant medication

Yes No

concentration problems or ADD/ADHD diagnosis

Yes No

alcohol/recreational drug use

Yes No

Are You

presently being treated for any other illness

Yes No

aware of a change in your health in the last 24 hours (e.g., fever, chills, new cough, or diarrhea)

Yes No

taking medication for weight management

Yes No

taking dietary supplements

Yes No

often exhausted or fatigued

Yes No

experiencing frequent headaches or chronic pain

Yes No

a smoker, smoked previously or other (smokeless tobacco, vaping, e-cigarettes, and cannabis)

Yes No

considered a touchy/sensitive person

Yes No

often unhappy or depressed

Yes No

taking birth control pills

Yes No

currently pregnant

Yes No

diagnosed with a prostate disorder

Yes No

List any current medical treatment, impending surgery, genetic/development delay, or other treatment that may possibly affect your dental treatment.

List all medications, supplements, and or vitamins taken within the last two years

Please provide a list of any allergies you have experienced

Consent

I hereby authorize:

any available insurance benefits to be paid directly to my dentist,
the release of my dental health care information for any of my dental health care insurance claims,
the use of my dental records by my dentist in any professional manner that he/she determines,
the making of videotapes, photographs, and x-rays of my dental care treatment (collectively “My Images”),
my dentist's use of My Images in scientific papers, demonstrations, and/or presentations without compensation to me.

I agree that to the extent the cost of the dental care provided by my dentist is not covered by insurance, I am obligated to pay him/her such uninsured costs (the “Uninsured Costs”) in accordance with his/her payment terms and policies. Finally, I certify that I have read or had read to me the contents of this form and understand the risks and limitations involved with the dental treatment that I am to receive.

Sign Below

Privacy Practices & Submission

Dr. Nathan Powers, DMD
NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practice, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect June 1st , 2016, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations included quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative, or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experiences with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders(such as voicemail messages, postcards, or letters)

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $.50 for each page, to locate and copy your health information, and postage if want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary of an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before July 4 th 2016. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosures of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations.{You must make your request in writing.} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our Website or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer: Dr. Nathan Powers, DMD
Telephone: 513-271-6322
Email: Nathan.PowersDMD@gmail.com
Address: 6839 Wooster Pike, Mariemont, OH 45227

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
You may refuse to sign this acknowledgement*

Patient Forms

Dev Mode

Welcome to Our Dental Practice!

Patient Information

Emergency Contact

Dental Insurance

Dental History

Medical History

Consent

Privacy Practices & Submission

General Information

Employer Information

Spouse Information

Misc. Information

Emergency Contact Information
Person We May Contact In Case Of An Emergency (Other Than Your Family Home)

Dental Insurance

Dental History

Personal History

Gum And Bone

Tooth Structure

Bite And Jaw Joint

Smile Characteristics

Medical History

Do You Have Or Have You Ever Had

Are You

List all medications, supplements, and or vitamins taken within the last two years

Please provide a list of any allergies you have experienced

Consent

Sign Below

Privacy Practices & Submission

Sign Below

Patient Forms

Dev Mode

Welcome to Our Dental Practice!

Patient Information

Emergency Contact

Dental Insurance

Dental History

Medical History

Consent

Privacy Practices & Submission

General Information

Employer Information

Spouse Information

Misc. Information

Emergency Contact Information Person We May Contact In Case Of An Emergency (Other Than Your Family Home)

Dental Insurance

Dental History

Personal History

Gum And Bone

Tooth Structure

Bite And Jaw Joint

Smile Characteristics

Medical History

Do You Have Or Have You Ever Had

Are You

List all medications, supplements, and or vitamins taken within the last two years

Please provide a list of any allergies you have experienced

Consent

Sign Below

Privacy Practices & Submission

Sign Below

Emergency Contact Information
Person We May Contact In Case Of An Emergency (Other Than Your Family Home)