Date Upperman Family Dental NEW PATIENT REGISTRATION First Name Middle Initial Last Name Patient is: Policy Holder Responsible Party Preferred Name Address Address 2 City, State, Zip Home Phone Cell Phone May we send text messages? Yes Email Address May we email you? Yes Employer Employer Phone Male Female Marital Status Married Single Divorced Separated Widowed Date of Birth Age Soc Sec Drivers License Employment Status Full Time Part Time Retired Referred by Student Status Full Time Part Time Previous Dentist Emergency Contact Name Pharmacy Emergency Contact Phone Number Responsible Party (only if other than the patient) First Name Middle Initial Last Name Address Address 2 City, State, Zip Home Phone Cell Phone Email Address Date of Birth Age Soc Sec Drivers License Employer Employer Phone When was your last dental checkup? Do you have any dental problems? Please explain Have you noticed or has any dentist/hygienist ever said you Have gum disease Have loose teeth or fillings Grind your teeth Bad Breath Clicking or popping jaw Sores, blisters or growths Jaw pain or tiredness Pain around ear Lip or cheek biting Have food collecting between teeth Sensitivity to Cold Heat Sweets Biting or chewing Would you like to know what options are available for you to Create a more attractive smile? Keep your teeth for life? PLEASE provide office staff with your insurance card / insurance information
Patient Consent Form The Department of Health and Human Services has established a Privacy Rule to help insure that personal health care information is protected for privacy. The Privacy Rule was also created in order to provide a standard for certain health care providers to obtain their patients consent for uses and disclosures of health information about the patient to carry out treatment, payment, or health care operations. As our patient we want you to know that we respect the privacy of your personal dental records and will do all we can to secure and protect that privacy. We strive to always take reasonable precautions to protect your privacy. When it is appropriate and necessary, provide the minimum necessary information to only those we feel are in need of your health care information and information about treatment, payment or health care operations, in order to provide health care that is in your best interest. We also want you to know that we support your full access to your personal dental records. We may have indirect treatment relationships with you (such as laboratories that only interact with doctors and not patients), and may have to disclose personal health information for purposes of treatment, payment, or health care operations. These entities are most often not required to obtain patient consent. You may refuse to consent to the use or disclosure of your personal health information, but this must be in writing. Under this law, we have the right to refuse to treat you should you choose to refuse to disclose our Personal Health Information (PHI). If you choose to give consent in this document, at some future time, you may request to refuse all or part of your PHI. You may not revoke actions that have already been taken which relied on this or previously signed consent. If you have any objections to this form, please ask to speak with our HIPAA Compliance Officer. It should be noted that while we make an effort to keep conversations in the treatment areas private, it may not always be possible to do so. Our office is an open and friendly environment and most patients appreciate this, however, it is possible that conversations could be overheard under some circumstances. Should you desire a completely private area to discuss your dental treatment, please make it known to the staff and we will provide one as soon as possible. You have the right to review our privacy notice, to request restrictions and revoke consent in writing after you have reviewed our privacy notice. I have read and approve Upperman Family Dental Patient Consent Form Print Name Signature Date Compliance Assurance Notification for our Patients Dear Valued Patients: The misuse of Personal Health Information (PHI) has been identified as a national problem causing patients inconvenience and money. We want you to know that all of our employees, managers and doctors continually undergo training so that they may understand and comply with government rules and regulations reporting the Health Insurance Portability and Accountability Act (HIPAA) with particular emphasis on the Privacy Rule. We strive to achieve the very highest standards of ethics and integrity in performing services for our patients. It is our policy to properly determine appropriate use of PHI in accordance with the governmental rules, laws and regulations. We want to ensure that our practice never contributes in any way to the growing problem of improper disclosure of PHI. As part of this plan, we have implemented a Compliance Program that we believe will help us prevent any inappropriate use of PHI. We also know that we are not perfect! Because of this fact, our policy is to listen to our employees and our patients without any thought of penalization if they feel that an event in anyway compromises our policy of integrity. More so, we welcome your input regarding any service problem so that we may remedy the situation promptly. THANK YOU FOR BEING ONE OF OUR HIGHLY VALUED PATIENTS.
111 Upperman Lane Baxter, Tennessee, 38544 931-858-3181 INFORMED CONSENT FOR GENERAL DENTAL PROCEDURES You have the right to accept or reject dental treatment recommended by your dentist. This form lists an overview of potential risks and complications. Prior to consenting to treatment, you should carefully consider the anticipated benefits, commonly known risks and complications of the recommended procedure, alternative treatments or the option of no treatment. It is very important that you provide your dentist with an accurate medical history including allergies before, during and after treatment. It is equally important that you follow your dentist s advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled follow up appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. During your course of treatment the following care may be provided to you: EXAMINATIONS AND X-RAYS Radiographs are required to complete your visit, diagnosis and treatment. A periodic examination will be provided by the dentist at all routine cleanings to evaluate your teeth for decay, gum disease, oral cancer and overall health. DENTAL PROPHYLAXIS (CLEANING) A routine dental prophylaxis involves the removal of plaque and calculus above the gum line and will not address gum infections below the gum line (gum disease). Some bleeding after a cleaning can occur, however, should it persist and if it is severe in nature the office should be contacted. PERIODONTAL TREATMENT Periodontal disease is an infection causing gum inflammation and/or bone loss that can lead to tooth loss. If you present with an infection during your routine cleaning appointment it may be necessary for more extensive treatment to be performed. The success of any periodontal treatment depends in part on your efforts to brush and floss daily, receive regular cleanings as directed, follow a healthy diet, avoid tobacco products and follow any other recommendations. RESTORATIONS (FILLINGS) A more extensive restoration than originally diagnosed may be required due to additional decay or unsupported tooth structure that can only be found during preparation of the tooth. This may lead to root canal, crown or both. Sensitivity is a common aftereffect of a newly placed filling. Occasionally after receiving a filling it may feel high and you may need to return to have the bite adjusted. CROWNS, BRIDGES and VENEERS It is not always possible to match the color of natural teeth exactly with artificial teeth. A temporary crown will be made after the initial preparation appointment. Temporary crowns may come off and you should be careful chewing on them until the permanent crowns are delivered. If a temporary crown should fall off call the office immediately. The final opportunity to make changes on crowns, bridges or veneers (including shape, fit, size, placement and color) will be done before permanent cementation. In some cases, crowns, bridges and veneer procedures may result in the need for future root canal treatment, which cannot always be predicted or anticipated. After a crown, bridge or veneer is permanently cemented sometimes your bite may feel high and you may need to return to have the bite adjusted or fixed. Modification of daily cleaning procedures may be required and if so will be explained to you by your provider. TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMD) Symptoms of popping, clicking, locking and pain can intensify or develop in the joint of the lower jaw (near the ear) subsequent to routine dental treatment when the mouth is held in the open position. However, symptoms of TMD associated with dental treatment are usually temporary in nature and well tolerated by most patients. If need for treatment should arise, you will be referred to a specialist, the cost of which is your responsibility. Changes in Treatment Plan I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination. The most common being root canal therapy following routine restorative procedures. I give my permission to the dentist to make any/all changes and additions as necessary. Allergies/Medication I have informed the dentist of any known allergies I may have. I understand that medications can cause allergic reactions causing redness and swelling of tissues; pain, itching, vomiting and/or anaphylactic shock (severe allergic reaction). They may cause drowsiness, lack of awareness and coordination which can be increased by the use of alcohol or other drugs. I understand that failure to take medications prescribed to me as directed may offer risks of continued or aggravated infection, pain or a negative result on the outcome of my treatment. I understand that antibiotics can reduce the effectiveness of oral contraceptives (birth control pills). Consent I have read each paragraph above and consent to recommended treatment as needed. I understand the anticipated benefits and commonly known risks and complications of each procedure. Patient s Name Signature of Patient/Legal Guardian Date Signature of Witness
Payment Agreement Printed Name Upperman Family Dental Policy requires that full payment is made at the time service is provided. We accept most insurance plans and will be happy to bill your insurance company that is within our network for payment. Any copays or amounts not covered by networked insurance companies must be paid in full at the time of service. If necessary, we will accept half of the amount due for crowns, bridges, and dentures that require lab work. You, the patient, are responsible to provide any change in insurance status to office staff prior to service being provided. You are also responsible for your eligibility with your insurance company and to know what benefits, deductibles, co-pays, and remaining benefits you have. If you have any questions, just ask our office staff prior to your treatment. I understand that I am responsible for the entire cost of treatment. I further understand that if it ever becomes necessary for the account to be turned over to collection, I am responsible for any collection and/or attorney fees. I agree to provide payment for treatment I receive at the time service is provided. Insurance Statement I authorize the release of any information needed to process my insurance claims. I further understand that I am responsible for entire cost of treatment regardless of insurance coverage or payments. I understand that UFD will provide estimates regarding insurance reimbursements but I am ultimately responsible for obtaining insurance payment amounts from my insurance company. I authorize payment of insurance benefits directly to the dentist otherwise payable to me. Acknowledgement of Receipt of Privacy Practices Notice I hereby acknowledge that I have received a Notice of Privacy Practices from Upperman Family Dental Release of Dental Information Please indicate who you authorize to have access to your dental information. Authorized person/persons Updated 7/25/17