Online Patient Information Form Is patient covered by additional insurance?
I certify that I, and/or my dependent(s), have insurance coverage with
all insurance benefits, if any, otherwise payable to me
for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named dentist may use my health care information and may disclose such information to the
above-named Insurance Company(ees) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions pertaining both your dental and medical history.
Date of last dental visit Date of last dental X-rays PLEASE MARK "YES" OR "NO" TO INDICATE IF YOU HAVE HAD ANY OF THE FOLLOWING:
Blisters on lips or mouth
Cigarette, pipe or cigar smoking
Burning sensation on tongue
Chew on one side of mouth
Food collection between teeth
Loose teeth or broken fillings
Sores or growths in your mouth
Are you allergic to any of the following:
Are you under a physician's care now?
Are you taking any pills, medication or drugs?
Are you on a special diet?
Have you ever been hospitilized or had a major operation?
Do you take, or have taken, Phen-Fen or Redux?
Have you ever had a serious head or neck injury?
Have you ever taken Fosamax, Boniva, Actonel or any other medication containing bisphosphonates?
Do you use controlled substances?
DO YOU HAVE, OR HAVE HAD, ANY OF THE FOLLOWING?
Cold Sores/Fever Blisters
Congenital Heart Disorder
Fainting Spells/Dizziness
Stomach/Intestinal Disease
Have you ever had any serious illness not listed above?
Comments
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.
NOTICE OF PRIVACY PRACTICE ACKNOWLEDGEMENT & PATIENT CONSENT FORM
I understand, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health/dental information. I understand this information can and will be used to:
Conduct, plan and direct my treatment and follow up among multiple healthcare providers who may be involved in my treatment directly and/or indirectly.
Conduct normal healthcare operations, such as physician certifications and assessments.
Obtain payment from third party payers, such as insurance companies.
Confirm and leave messages at phone numbers provided to this office.
I have been informed of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this office has the right to change its Notice of Privacy Practices from time to time and that I may contact this office at anytime to obtain a current copy of the Notice of Privacy Practices.
I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or dental care operations. I also understand you are not required to agree to my restrictions, but if you do agree then you are bound to abide by such restrictions.
Additional family members given access
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