Patient Forms

Thank you for choosing our practice for your dental needs! Spend more time at your appointment with Dr. Miller, and less time filling out paperwork in our lobby. Complete our new patient forms below at your own convenience, prior to your first appointment with us.

If you have any questions, please give us a call at (219) 836-4214.

Patient Dental & Medical Health History Information
To our patients: Please know that we may ask follow-up questions to make sure we have all of the information we need in order to treat you.
Name
Name
First
Last
Address
Address
City
State/Province
Zip/Postal
Gender
Emergency Contact Name
Emergency Contact Name
First
Last
If you are completing this form for another person, what is your name and relationship to that person?
Name
Name
First
Last
If executing this form as the patient’s personal representative, I represent and warrant that I have full legal right and authority to consent to the performance of any procedure(s) on this patient. If for any reason I no longer have such legal right and authority, I will immediately notify the practice in writing.

Dental History & Symptoms

Are you currently experiencing any dental pain or discomfort?
Please select each box that applies to you.
Have you ever experienced any of these sleep-related breathing disorders or been diagnosed with some form of sleep apnea by a physician?
Have you ever had a serious injury to your head or mouth?
Have you ever had problems with dental treatment in the past?
Have you ever had a reaction to, or problem with, dental anesthesia?
Are you unhappy with your smile?
If yes, why? Please mark all that apply

MEDICATIONS & OTHER PRODUCTS/SUBSTANCES

Are you taking or have you taken any blood thinners (such as Coumadin, Warfarin, rivaroxaban (Xarelto®), dabigatran (Pradaxa®), clopidogrel (Plavix®), heparin or aspirin)?
Are you taking or have you taken any medication to treat osteoporosis or Paget’s disease?
Some commonly-prescribed drugs include alendronate (Fosamax®), risedronate (Actonel®), ibandronate (Boniva®), zolendronate (Reclast®), and denosumab (Prolia®).
Are you taking, scheduled to take, or have you taken an IV medication to treat bone pain, hypercalcemia or skeletal complications resulting from Paget’s disease, multiple myeloma or metastatic cancer?
Some commonly-prescribed drugs include denosumab (Xgeva®), pamidronate (Aredia®) or zolendronate (Zometa®).
Are you taking hormonal replacements?
Do you use any form of tobacco or nicotine products (cigarettes, cigars, snuff, chew, bidis)?
Do you use vaping products?
Do you use controlled substances (drugs), including marijuana, for either medicinal or recreational reasons?
If yes, how often is your use?
Was the substance prescribed by a doctor?
Do you take any other prescriptions and/or over-the-counter medicine(s), vitamins, herbs and/or supplements?
Are you taking birth control pills?
Are you pregnant?
Are you nursing?

ALLERGIES

Select all items you are allergic to or you have had an allergic reaction to

MEDICAL & SURGICAL HISTORY

Are you in good physical health?
Are you currently being seen or treated by a physician?
Has a physician or previous dentist recommended that you take antibiotics before having dental work done?
Have you had a serious illness, operation or been hospitalized in the past 5 years?
Have you had any type (either total or partial) of joint replacement surgery (such as for a hip, knee, shoulder, elbow, finger, etc.)?
Have you had a heart valve replacement or heart surgery?
Have you had an organ or bone marrow/stem cell transplant?
Have you traveled internationally within the last 30 days
Have you had a fever (100.4F or above) in the last 72 hours?

MEDICAL HISTORY SPECIFIC

Do you have, or have you been diagnosed with, any of the following Heart (Cardiac) Health conditions? Select all that apply
Do you have, or have you been diagnosed with, any of the following Breathing (Respiratory) Health conditions? Select all that apply
Do you have, or have you been diagnosed with, any of the following Blood (Circulatory) Health conditions? Select all that apply
Do you have, or have you been diagnosed with cancer?
Do you have, or have you been diagnosed with, any of the following Brain (Neurological)/Mental Health conditions? Select all that apply
Do you have, or have you been diagnosed with, any of the following Digestive Health conditions? Select all that apply
Do you have, or have you been diagnosed with, any of the following conditions? Select all that apply
Do you have any disease, condition, or problem that’s not listed here?

MEDICAL SYMPTOMS/GENERAL

In the past 30 days, have you (select all that apply)

NOTE: It’s important for both the doctor and patient to talk honestly about the patient’s health before dental treatment starts.

I have answered the above questions completely, accurately and to the best of my ability

HIPPA Notice

Jamila D. Miller, D.D.S., L.L.C. Notice of Privacy Practices has been offered to me.  I understand I have the right to review the Notice of Privacy Practices Prior to signing this document and by signing this document, acknowledge only that I have been offered the Notice of Privacy Practices or have declined the offer.

Jamila D. Miller, D.D.S., L.L.C. reserves the right to change the privacy practices that we described in the Notice of Privacy Practices.  

I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail, asking for one at the time of my next appointment.  

Name of Patient
Name of Patient
First
Last
I authorize the following person(s) minimal access (Does not include copies of medical records) to my protected health information (PHI).

Authorized Person

Name
Name
First
Last
plus1 Add another person minus1 Remove a person
For authorization to release limited PHI to the above listed individuals.
I understand that by submitting this online form, I authorize Jamila D. Miller, D.D.S., L.L.C. to communicate with me electronically through e-mail.

Self Evaluation
Name
Name
First
Last

In order to provide the best care to you, it is important for us to know what is most important to you. Please rate the following in importance to you: 
1-Lower Importance → 5-Greater Importance

HIPAA Notice

Jamila D. Miller, D.D.S., L.L.C. Notice of Privacy Practices has been offered to me.  I understand I have the right to review the Notice of Privacy Practices Prior to signing this document and by signing this document, acknowledge only that I have been offered the Notice of Privacy Practices or have declined the offer.

Jamila D. Miller, D.D.S., L.L.C. reserves the right to change the privacy practices that we described in the Notice of Privacy Practices.  

I may obtain a revised Notice of Privacy Practices by calling the office and requesting a revised copy be sent in the mail, asking for one at the time of my next appointment.  

Name
Name
First
Last
I authorize the following person(s) minimal access (Does not include copies of medical records) to my protected health information (PHI).

Authorized Person

Name
Name
First
Last
plus1 Add another person minus1 Remove a person
For authorization to release limited PHI to the above listed individuals.
I understand that by submitting this online form, I authorize Jamila D. Miller, D.D.S., L.L.C. to communicate with me electronically through e-mail. Copy

Denture Questionnaire (if applicable)
Name
Name
First
Last
What do you think your denture(s) should do for you? (Please select at least TWO)

Continuing Guarantee of Payment
Guarantor Name
Guarantor Name
First
Last
Address
Address
City
State/Province
Zip/Postal

FOR: Professional services rendered or to be rendered to guarantor or family member(s). Guarantor agrees to be responsible to Jamila D. Miller D.D.S., L.L.C, for payment of services rendered or to be rendered to guarantor and family member(s). Fees are given before treatment is begun. Payment arrangements must be made prior to beginning treatment. We are an out-of-network providing office. Filing to insurance companies is a courtesy that we do on our patient’s behalf. All insurance reimbursement is sent directly to the subscriber/patient. All attorney fees, collection and court costs will be the guarantor’s responsibility in the event judicial action becomes necessary. Failure on the part of Jamila D. Miller D.D.S., L.L.C., to pursue legal action upon default shall not be deemed a waiver of any rights hereinabove described. After 90 days of inactivity a 10% interest fee will be added to delinquent accounts monthly. We have the right to send all delinquent account to collections after 90 days of inactivity.

Nasal Obstruction Symptom Evaluation (NOSE) Scale
Name
Name
First
Last
Over the past month, how much of a problem were the following conditions for you?
Nasal congestion or stiffness
Nasal blockage or obstruction
Trouble breathing through my nose
Unable to get enough air through my nose during excursive or exertion
Add the 5 questions above
Your score multiplied by 5

Nasal obstruction severity classification:

Mild (5-25)

Moderate (30-50)

Severe (55-75)

Extreme (80-100)

The Epworth Sleepiness Scale

(To assess risk of Obstructive Sleep Apnea)

Name
Name
First
Last
Your Sex

Use the following scale to choose the most appropriate number for each situation:

0 = Would never doze
1 = Slight chance of dozing
2 = Moderate chance of dozing
3 = High chance of dozing

It is important that you answer each question as best you can.

Score:
0-10 Normal range
10-12 Borderline
12-24 Abnormal

STOP-Bang Sleep Apnea Screening Tool
Answer each of the following “yes” or “no”
Do you SNORE loudly (louder than talking or loud enough to be heard through closed doors?)
Do you often feel TIRED, fatigued, or sleepy during daytime?
Has anyone OBSERVED you stop breathing during your sleep?
Do you have or are your being treated for high blood PRESSURE?
BMI more than 35?
AGE year 50 years old?
> 3 “yes” answers= High- risk for OSA
NECK circumference > 15.75 inches?
Male GENDER?
< 3 “yes” answers= Lower-risk for OSA