HEALTH HISTORY

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FORMS

No patient is seen without a current health history, the form for which is provided here. Note: current medications, vitamins, and supplements lists can often be printed out by nursing home staff so you don’t have to write it out on the health history form. Please forward the patient’s most current dental x-rays to Lauren.

PATIENT INFO

The patient information form is necessary to reach patients and their support team, as well as to submit insurance claims as a courtesy facilitating patient reimbursement by their carrier. So, please fill the form out completely, and if your voice mailbox is full then provide a more reliable form of contact. Please provide documentation of power of attorney, if applicable.

Patients must provide an annual standing order from a dentist or primary care physician to continue dental hygiene services. At minimum, the following text shall be written on a doctor’s letterhead: This is a standing order permitting [patient name] to have dental hygiene services provided on-site by Lauren K. Chin, RDHAP with antibiotic premedication coverage and application of topical fluoride varnish as needed. Note to healthcare professionals: please indicate in your standing order whether you want to conduct dental exams yourself, or provide restorative care yourself.

REFERRAL SLIP

Are you a healthcare provider who wants to refer a patient to Lauren? Use these referral slips. Note: if you want the patient to have antibiotic premedication, then please provide the patient with the prescription. Note to healthcare professionals: please indicate in your referral if you will conduct dental exams yourself, or provide restorative care yourself.