Richard Bowen, DDS www.bowenlegacydental.com Taryn Gehlert, DDS Tel:614-459-2300 General, Cosmetic & Implant Dentistry 770 Jasonway Ave   Columbus, OH 43214 Patient Information Date: Our passion is to provide you with a totally different experience. Giving you the results you are seeking with better commun ication and treatment options. We are creators of new lifestyles through smiles. Dr. Mr. Mrs. Ms. Name: I prefer to be called: Person Responsible for account: Relationship: Home Address: City: State: Zip: Marital Status: Single Married Separated Widow(er) Home Phone: Work Phone: Cell: Email: Where do you prefer to receive calls? Birth date: Soc.Sec# Drivers Lic.# What is your occupation?: Employer Name of Spouse or Parent if Minor If Patient is a minor, Mother & Father's names & birthdates: How did you hear about our office? Internet search Online Reviews Print Media Personal Referral Social Media Personal referral: If so, whom may we thank? EMERGENCY INFORMATION In case of emergency who should we contact? Name: Phone: Relation: INSURANCE INFORMATION Do you have dental insurance?: Yes No If yes, which carrier? Policy holder name: DOB: SS#: Employer: Insurance Company: Address: Phone: Group#: Policy#: Do you have secondary insurance? Initials: Date: Richard Bowen, DDS www.bowenlegacydental.com Taryn Gehlert, DDS Tel:614-459-2300 General, Cosmetic & Implant Dentistry 770 Jasonway Ave   Columbus, OH 43214 HEALTH HISTORY Name of personal physician: Phone# Date of last physical: How do you assess your current health? Excellent Good Fair Poor Are you currently under the care of a physician? YES NO Please list any specialists you see and their specialty Please mark any that apply: Acid Reflux Anxiety AIDS/HIV Arthritis, Rheumatism Artificial Heart Valves Artificial Joints Autoimmune Disease Bell's Palsy Bleeding Abnormally Blood Disease Cancer Chemotherapy Clenching Circulatory Problems Congested Ears Cortisone Treatments Cough, Persistent Diabetes Type Depression Epilepsy Fainting or Dizziness Facial Pain GERD Glaucoma Grinding Heart Lesions Heart Murmur Heart Problems Headaches Hepatitis Type High Blood Pressure High Cholesterol Jaw Pain Jaw Popping Kidney Disease Limited Opening Liver Disease Lyme Disease Mitral Valve Prolapse Mold Exposure Neck Ache Nervous Problems Pacemaker Posture Problems Pregnant Psychiatric Care Radiation Treatment Rheumatic Fever Scarlet Fever Sinus Trouble Sleep Apnea Stroke Swollen Feet or Ankles Swollen Neck Glands Thyroid Problems Tonsillitis Tuberculosis Tumor/Growth in head Ulcer Please list any allergies: Have you taken or are you currently taking medications for osteoporosis known as bisphosphonates? (For example Fosamax, Acton el or Boniva) : YES NO If yes, medication name: Dates Do you smoke or use chewing tobacco? How much? For how long? In the last 5 years have you seen a Chiropractor Massage Therapist Neurologist ENT Are you currently taking prescription medications? If yes, please list name dosage and purpose Initials: Date: Richard Bowen, DDS www.bowenlegacydental.com Taryn Gehlert, DDS Tel:614-459-2300 General, Cosmetic & Implant Dentistry 770 Jasonway Ave   Columbus, OH 43214 DENTAL HISTORY If you could wave a wand and change anything you could about the appearance of your smile, what would you want different? What was the date of your last dental visit? Previous Dentist Name City, State Phone Have you ever had a less than positive dental experience? If so, please explain Have you seen an Orthodontist, had your bite adjusted, or been treated for TMJ? What is the most important thing to you about your future smile and dental health? What is the most important thing to you about your visit today? If you could whiten your teeth for a cost anyone could afford, would you do it? Have you professionally whitened before? YES NO Please check any of the following that applies to you: On a scale of 1-10, with 10 being the highest rating: Bad breath or bad taste in your mouth Bleeding, swollen or irritated gums Broken tooth or fillings Clicking, popping in jaw joint Grinding or clenching teeth Headaches, ear aches, neck pain Jaw joint pain Loose, tipped or shifting teeth Mouth ulcers or cold sores Muscle pain in the jaw, temple region, neck area Sensitivity Tooth pain or discomfort when chewing Trouble sleeping Snoring How important is your dental health to you? 1 2 3 4 5 6 7 8 9 10 Where would you rate your current dental health? 1 2 3 4 5 6 7 8 9 10 Importance of my overall health? 1 2 3 4 5 6 7 8 9 10 Importance of preventive care to me? 1 2 3 4 5 6 7 8 9 10 Importance of a cosmetic smile? 1 2 3 4 5 6 7 8 9 10 How often do you brush your teeth? How often do you floss? What other dental aids do you use? (Electric toothbrush, Water-Pik, toothpicks, Soft-Picks, etc) Initials: Date: Richard Bowen, DDS www.bowenlegacydental.com Taryn Gehlert, DDS Tel:614-459-2300 General, Cosmetic & Implant Dentistry 770 Jasonway Ave   Columbus, OH 43214 CONSENT TO DENTAL PHOTOGRAPHY I, authorize Bowen Legacy Dental, to take photographs, and/or videos of my face, jaws and teeth, before during and after treatment. I consent to allow the photographs to be used for the follow: 1) Dental Records 2) Dental Research 3) Dental Education including lectures, seminars, demonstrations and professional publications such as journals or books 4) Marketing material, including websites and printed materials, patient education and social media posts I further understand that if the photographs and/or videos are used, my full name and/or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these photographs. Patient Signature: Date   -OR-   I do not want my full-face shot used for any of the above purposes Patient Signature: Date Richard Bowen, DDS www.bowenlegacydental.com Taryn Gehlert, DDS Tel:614-459-2300 General, Cosmetic & Implant Dentistry 770 Jasonway Ave   Columbus, OH 43214 FINANCIAL GUIDELINES We are committed to providing you with the highest quality lifetime dental care, so that you may fully attain optimum oral health. Please understand that the payment of your bill is considered part of your treatment. We are a fee for service practice and collect in full at the time of service. If you have insurance, you will pay in full at the time of service and your insurance will reimburse you directly. We are committed to making decisions for each patient based on what is best for your overall health. Our office accepts cash, personal checks, MasterCard, Visa, Discover and CareCredit. Do you have insurance? As a courtesy to you, we are happy to file your dental claim on your behalf. Please note that Dr. Bowen is an in network provider with Delta Dental Premier and Dr. Gehlert is not an in network provider with any insurance companies. We will provide you with an insurance estimate. Understand this is not a guarantee of payment. Your insurance company and your plan benefit ultimately determine the amount paid. All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. We thank you for the opportunity to serve your dental health care needs and welcome any questions you may have concerning our financial policy. I have read, understand and agree to the above conditions. Patient Signature: Date Richard Bowen, DDS www.bowenlegacydental.com Taryn Gehlert, DDS Tel:614-459-2300 General, Cosmetic & Implant Dentistry 770 Jasonway Ave   Columbus, OH 43214 ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES I, have received a copy of this office's Notice of Privacy Practices.   Signature: Date   *You may refuse to sign this acknowledgement*   Refusing: Date     HIPAA Release of Information   I, authorize the release of information including the diagnosis, records; examination rendered to me and claims information. This information may be released to:   Spouse Child(ren) Other Information is not to be released to anyone   This release of information will remain in effect until terminated by me in writing.     Messages Please call: My home My work My cell   If unable to reach me: You may leave a detailed message Please leave me a message asking me to return your call   The best time to reach me is (day) between (times)   Signature Date   Witness Date   Richard Bowen, DDS www.bowenlegacydental.com Taryn Gehlert, DDS Tel:614-459-2300 General, Cosmetic & Implant Dentistry 770 Jasonway Ave   Columbus, OH 43214 OXYGEN/OZONE THERAPY INFORMED CONSENT I, , do voluntarily, knowingly, and willingly give my consent to the administration of dental oxygen/ozone treatments. I seek this treatment at my own request. I understand that dental oxygen/ozone therapy involves the injection of mixture of oxygen and ozone in the form of a gas with or without local anesthetic, into the skin, mucous membranes, muscles, joints, jawbones, and teeth of the head, neck and associated structures. Dental oxygen/ozone therapy is defined as the creation of a therapeutic oxygen rich environment, which induces a multi-factorial positive biochemical and following dental relevant and useful properties: it kills bacteria, viruses, fungi and parasites. It is circulatory stimulant, a wound-cleanser, and accelerant for wound healing, a hemostatic agent, and an immune activating agent. There may be other effects that at this time are unknown. I understand that I should tell the doctor or staff if. I have ever had an allergic reaction to any anesthetic, particularly dental anesthetics prior to any treatment involving injections with anesthetics. There are potential side effects with all types of dental treatments. Dental oxygen/ozone therapy carries with it some risk of side effects, such as: pain and/or discomfort at the injection site, soreness and temporary bruising. There may be a red, inflamed, blister type area at the injection site. This area usually heals a 1-5-day time period. All types of medications have some risk of allergic reactions. An allergic reaction to the mixture of oxygen/ozone would be unusual and usually restricted to the injection site. The most common patient comment is that there is a warm to burning sensation at the site of the injection. Some patients any experience flu-like symptoms for 2 to 3 days following treatment. Patient/Legal Guardian: Date Witness: Date Please enter code above in the field below.