How likely are you to doze off or fall asleep in the following situations, in contrast to feeling just tired? This refers to your usual way of life in recent times. Even if you haven't done some of these things recently try to work out how they would have affected you. Use the following scale to choose the most appropriate number for each situation:
0 = would never doze
1= slight chance of dozing
2 = moderate change of dozing
3 = high chance of dozing
It is important that you answer each question as best you can.
Sitting and reading
Sitting, inactive in a public place (e.g. a theater or a meeting)
As a passenger in a car for an hour without a break
Lying down to rest in the afternoon when circumstances permit
Sitting and talking to someone
Sitting quietly after a lunch without alcohol
In a car, while stopped for a few minutes in traffic
Usual bedtime (lights out)
Normal wake time (lights on)
Average number of times waking up at night
Feel refreshed when waking up?
Have you or your bed partner noticed snoring?
Have you or your bed partner noticed gasping for air?
Have you ever been diagnosed with periodontal (gum) disease?
Do you have any loose teeth?
Do you have any tooth pain?
Have you ever been diagnosed with TMD/TMJ?
Has your jaw ever been locked in the open position or had pain in the jaw joint?
Do you clench or grind your teeth?
Are you currently under the regular care of a dentist?
Please upload dental x-rays if taken within the past year:
Please write which of the illnesses you had or currently have in the entry box below:
Allergy - Latex
Allergy - Anesthetics
Allergy - Other
Artificial Joints (specify)
Blood Disease (specify)
Taking Blood Thinner
High Blood Pressure
Mitral Valve Prolapse
Please upload pictures or scan of your medical insurance card.
Primary Insurance (front of card):
Primary Insurance (back of card):
Secondary Insurance (front of card):
Secondary Insurance (back of card):
Consent for Services and Financial Policy
GENERAL CONSENT TO DIAGNOSE AND TREAT: The undersigned hereby authorizes Spira Dental to take radiographs, study models, photographs, or any other diagnostic tools deemed appropriate to make a thorough diagnosis of the undersigned patient's dental condition and needs. I authorize Spira Dental to perform any and all forms of treatment, medication, and therapy that may be deemed necessary by the doctors. To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect or incomplete information can be dangerous to my / the patient's health. It is my responsibility to inform the dental office of any change in medical health or status.
FINANCIAL CONSENT: I understand the responsibility for payment of services provided for myself and my dependent(s) is mine. As a courtesy we will be happy to assist in filing insurance. The office will collect your estimated portion on the day service is rendered and wait 30 days to obtain the balance from my insurance. I understand that I am responsible for any portion of fees not covered by my medical insurance after 30 days. Spira Dental and staff will provide care based on the patient's needs and not based on insurance coverage. I authorize Spira Dental and their staff to verify insurance coverage, submit claims, and provide my insurance company with information required for processing claims. I also give permission to assign benefits directly to Spira Dental and for this company to handle any necessary claim appeals on my behalf.
I understand that I may inspect or copy the protected health information described by this authorization. I understand that at any time, this authorization may be revoked, when the office that receives this authorization receives a written revocation, although that revocation will not be effective as to the disclosure of records whose release I have previously authorized, or where other action has been taken in reliance on an authorization I have signed. I understand that my health care and the payment for my healthcare will not be affected if I refuse to sign this form. I understand that information used or disclosed, pursuant to this authorization, could be subject to re-disclosure by the recipient and, if so, may not be subject to federal or state law protecting its confidentiality.
I authorize this company to release any financial or medical/dental information to the following person(s) listed below:
Name of patient, parent, or guardian completing this form: