Dados de Safide do paciente
Para podennos proporcionar um Servigo Dental apropriado para voce, por
favor responda as perguntag abaixo, que contdm informagoes eobseruagoes
importantes para n6s.
.
Nome do Pacientc
(rittirno)
Data de Nascinrcnto'
Scxp
Endcreco Rua:
n.i
'
N.dq Social Security
aPt.:
No5ne da compania de seguro
Cidade
teleforp
data de nasc.
s.security
telefonc do trabalho'
Nonle da esposa(o)
quem?
Em caso dc emerg8ncia: nome e ielefonc
Q,r"l o seu estado de safdc? rurquc umx
excclentc(
Nome do scu mddico
ocuPaQa9
ceP
nome do empregado
Nomc e enderego do trabalho
VocE foi indicado por
(do mcio)
Grirrciro)
).
bor(
)
razo6ve(
)
rurn( )
Eirdercgp
)
-Voc0 esta tomando algum rem6dio? llES( ) NO(
Qual remidio e para
-Voct i alcrgioihd: pcnicilina( ) anestesla locql( ) ou outros( Quais?.
-Voc0 estdzujeita a um lorrgo periodo de sagrimento? reS(.) NO( )
-Voc8 estrigrivida? lTS( ) NO ( )
-Voc0 toma anticoncepcional? lES( )NO( )
-Voc0 jd foi tratadf'por atgum .dcstes motivos:
Doengas do coragEo...............YES( ) NO( )
... YES( ) NO( )
Febrc
baixa..............YEs(
alta
ou
PressE'o
) NO( )
Epileisia.................:............., YES( ) NO(
.
Leqdo cogenita do coracao,.... lES( ) NO( )
Sopro no cora9do................... YES( ) NO( )
Asma, Alergia,Sinusite........... YES( ) NO( )
i..,.-....... Es( ) NO( )
qu&--
)
.
reuma'tica..
)
Artritis.......
JJdata
assinalura do paciente
ass. dq dpntista
Instrug6es Pds Cirureia Oral
Depois de uma extragdo cinirgica se houverl
,
1.
SANGRAMENTO
Morder em gazes firmemente por t hora. Se
nenhum medicamento foi receitado, e recomenda'vel que 2 (dois)
comprimidos de Tylenol Extra forte ou Iboprofen sejam tomados a
cada 4 horas at€ anoite. E normal haver sangramento at6uma certa
quantidade, mas se continuar o sangamento depois de um certo tempo,
continue no procedimento de morder em gazes ou procure o dentista,
-
- Certo desconforto e noflnal apds uma extra96o.'Se tomar
Tylenol ou Iboprofen a dor pode ser aliviada. Se ....r mddicamentos
2. DOR
n6o s6o suficientes para a dbr, ent6o serd preciso voltar ao seu dentista
e medicamentos serSo receitados.
Apds uma extracdo complicadahd chances que possa
ocoffer inchago. Aplicagdes de gelo a cada 15 minutos ajuda em
reduzir inchago.
-
4. ENXAGUE BUCAL - Nenhum gargarejo/enxague
deve ser feito no
dia da extragSo (pode prolongar sangramento). No dia seguinte e
recomeda'vel que um erxague seja feito usando uma soluqdo de dgua
morna e sal (2 colheres de chd de sal em um copo m6dio com dgua *
morna). E recomenddvel que gargareje de 5 a lb vezes por dia,
durante 7 dias para melhor sicatrizagdo e limpeza.
- Durante o processo de cicatrizapdo e normal
que tenha pedagos pequenos de osso. Se pedaqos maiores de osso
estiverem encomodando favor procurar seu dentistaparaque seja
retirado.
DOR ou INCFIACO
@rocurar
-
Se dor ou inchaqo ocorrer depois da
seii dentista.
GEORGE J. SAWAN, D.M.D
JOSEPH S. SAWAN, D.M.D
2IRVING STREET
FRAMINGHAM, MA 01702
(s08) 620 -7162
,{DUSe
Aburse or
Or Neglect
We
Patient Rights
will notify government authorities if we believe
a patient is the victim of abuse, neglect or domestic violence.
will make this disclosure only when we are compelled
This new law is careful to describe that you have the following
rights related to your health information.
by our ethical judgment, when we believe we are specifically
required or authorized by law or with the patient's agreement.
Restrictions
We
You have the right to request restrictions on certain uses and disclosures
of your health information. Our office will make every effort to honor
reasonable restriction preferences from our patients.
Public Flealth and National ,security
We may be required to disclose to Federal officials
or military authorities health information necessary to complete
an investigation related to public health or national security.
Health information could be important when the government
believes that the public safety could benefit when
the information could lead to the control or prevention
of an epidemic or the understanding of new side effects
of a drug treatment or medical device.
Confi dential Communication
for confidential communications.
Inspect and Copy Your Health ln{brmation
You have the right to read, review, and copy your health
information, including your complete chart, x-rays and billing
records. If you would like a copy of your health information,
As permitted or required by State or Federal law, we may
disclose your health information to a law enforcement official
for cerlain law enforcement purposes, including, under certain
limited circumstances, if you are a victim of a crime
or in order to report a crime.
know We may need to charge you a reasonable fee
to duplicate and assemble your copy.
please let us
Amend Your Health Information
You have the
Family, Friends and Caregivers
as our office maintains this information. In order to standardize
our process, please provide us with your request in writing
and describe your reason for the change.
medications, or payment. We will be sure to ask your
permission first. In the case of an emergency, where you
are unable to tell us what you want we will use our very best
judgment when sharing your health information only when
it will be important to those participating
in providing your care.
Your request may be denied
['aticnt
Nane(s):
Documentation of Flealth Information
You have the right to ask us for a description ofhow and where
your health information was used by our office for any reason other
than for treatment, payment or health operations. Our documentation
procedures will enable us to provide information on health information
usage from April 14, 2003 and forward. please let us know in writing
the time period for which you are interested. Thank you for limiting
your request to no more than six years at a time. We may need
to charge you a reasonable fee for your request.
Request a Paper Cc,py of this Notice
:
You have the right to obtain a copy of this Notice of privacy
Practices directly from our office at any time. Stop by or give
us a call and we will mail or email a copy to you.
]
llhauk you very:nro!1l"f*:laking'tlme to review how. we ur.e car-etirlly usin.u
1,'ou-r lreallh infor.rruition."if you have any questions we wimt to hear liom r
you. If no{, we wotild appreciare very *u.h ynr ackncuiiedging your
rcceipt ol our policy by signing ancl rerurning trris carcl. We look tbru,ard ro
l
seeing 5,on agdin
Patient
sOonl
Sjgn'itpts:
:ri.::1,,'.,.,,
Dare
t
t
_-.:--._-==-=
the health information record
to be accurate and complete.
Other than is stated above or where Federal, State or Local law
requires us, we will not disclose your health information other
than with your written authorization. You may revoke that
authorization in writing at any time.
"
if
in question was not created by our office, is not part of our records
or if the records containing your health information are determined
Authorization to Lise or llisclose
F{ealth Information
..;i
right to ask us to update or modify your records
ifyou believe your health information records are incorrect
or incomplete. We will be happy to accommodate you as long
We may share your health information with those you tell
us will be helping you with your home hygiene, treatment,
Acknowledgmenr
your
health information privately with no other family members present
or through mailed communications that are sealed. We will make
every effort to honor your reasonable requests
For Law Enforcement
Patient
s
You have the right to request that we communicate with you
in a certain way. You may request that we only communicate
,'
'i
:,;
We are required by law to maintain the privacy of your health
information and to provide to you and your representative this Notice
of our Privacy Practices. We are required to practice the policies
and procedures described in this notice but we do reserve the right
to change the terms of our Notice. If we change our privacy practices
we will be sure all of our patients receive a copy of the revised Notice.
You have the right to express complaints to us or to the Secretary
of Health and Human Services if you believe your privacy rights
have been compromised. We encourage you to express any concerns
you may have regarding the privacy of your information. please
let us know of your concems or
ts in writing.