McAlpin Dental Group, P.A. Medical Update Patient Name:______________________________________________________DOB: ____________________ Emergency Contact:________________________________ Emergency Contact Ph. #: ____________________ Do you have or have you had any conditions listed below: Other (Please explain): ________________________________________________________________________
___________________________________________________________________________________________
Have you been treated with Bisphosphonate drugs (such as Fosamax, Boniva, Actonel, Aredia, Skelid and
Didronel)?___________________________________________________________________________________
Have you been to visit a physician since your last dental visit? Please list the name and phone number of your physicians:
1. ________________________________________________________________________________________
2.________________________________________________________________________________________
3. ________________________________________________________________________________________
Please list any medications, dosage & reason that you are taking:
1. _________________________________________
6. _________________________________________
2. _________________________________________
7. _________________________________________
3. _________________________________________
8. _________________________________________
4 _________________________________________
9. _________________________________________
5. _________________________________________
10. ________________________________________
Do you have any allergies or are you allergic to any medications?
If yes please Iist: ___________________________________________________________________________
________________________________________________________________________________________
WOMEN: Are you pregnant? Are you nursing? To the very best of my knowledge, the above information is true.
Patient Signature:_____________________________________________________Date: ____________________
Staff Signature:_______________________________________________________Dr. Initial: ________________
McAlpin Dental Group, P.A. Personal Information Update Patient Name:______________________________________________________DOB: ____________________ Home Address: ______________________________________________________________________________ City:____________________________________State:________Zip: _____________________ Home Phone:__________________________Cell:_________________________Work: ___________________ Email Address: ______________________________________________________________________________ Spouse’s Name:________________________________________ Spouse’s Phone #:_______________________ Emergency Contact (1): _______________________________________________________________________ Emergency Contact (2): _______________________________________________________________________ Dental Insurance Company ID/Group Number: ___________________________________________________ Dental Insurance Company Contact Number: _____________________________________________________
Patient Signature:_____________________________________________________Date: ____________________
This list is revised once a year- not all products listed may be gluten free at time of sale due to manufacturer's changes since the last revision. This list is a guide only. Gluten Free - ALL WIC NUMBER ITEM DESCRIPTION ACETYL L-CARNITINE 400MG W ALA 200MG CAPSULES ADULT LOW STR ENTERIC ASPIRIN 500S EZOPEN Good as of 06/30/2009 This list is revised once a year- not all products list
Information for Medicaid Pharmacy Providers and Prescribers Pharmacy Program Changes Effective October 1, 2011 Changes to the Ohio Medicaid Pharmacy program that will be effective on October 1, 2011: 1. Change in pharmacy billing and coverage for members of Medicaid-contracting managed 2. Change to fee-for-service Medicaid Preferred Drug List (PDL) Policy Guidance 1. Change in pha