ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Similar documents
PATIENT INFORMATION. Date: Patient Name: SS#: Address: City: State: Zip: Phone: (Home) (Work) (Cell)

MEDICAL HISTORY FULL NAME D.O.B. SEX

PATIENT INFORMATION. Address: Street City State Zip Home phone: Work phone: Cell phone: address: Patient s or parent s employer: Occupation:

Patient Registration

ATWOOD FAMILY DENTAL DENTAL REGISTRATION AND HISTORY

New Patient Paperwork

Last: First: MI: Nickname:

WELCOME Patient Registration Date:

PATIENT HEALTH HISTORY

Lake Forest Dental. Patient Information

Lake Forest Dental. Patient Information

Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes Yes No If yes. Yes No Yes No

AJ Dental Group, PC Family, Cosmetic & Implant Dentistry

MEDICAL HISTORY DO YOU HAVE OR HAVE YOU HAD ANY OF THE FOLLOWING PLEASE CHECK ALL THAT APPLY. Patients s Name Date Yes No Yes No

Prosthodontics and Implant Surgery

PATIENT MEDICAL HISTORY

Patient Information. Spouse or Responsible Party Information. Insurance Information

PAUL T. OLENYN D.D.S.

Welcome to Dr Jamie Italiane-DeCubellis s office

Twohig Dentistry Dental and Oral Health Information

Julia A. Hallisy, D.D.S., Inc.

Child Dental Registration

Name: Last First Middle. Address: Street or P.O. Box # City State Zip code Phone Number: Home: Work: Pager#: Cell Phone: Address:

(Please complete the enclosed forms prior to your visit and bring them in with you.)

PATIENT INFORMATION DENTAL HEALTH HISTORY

Patient Name: Physician s Name Phone # Date of last physical Place a mark on yes or no to AIDS/HIV. Yes No Liver Disease.

3. Have you had any serious illness, operation, or been hospitalized in the past five years? Venereal disease (STD s), Sickle cell disease medication

Kingsland Family Dental Registration and Medical History

MEDICAL AND PERSONAL HISTORY

Dear Patient, Sincerely, Dr. Edward Adourian. carlsbaddentalassociates.com. Dental Associates & Orthodontics EXCELLENCE IN DENTISTRY

Patient Name Last First MI Preferred Name SS# Date of Birth / / Drivers License # Home Address City Zip

White House Dental 347 West Idaho Avenue Ontario, Oregon (541) whitehousedental.net

Creating and maintaining your oral health is our primary goal. Thank you for giving us the opportunity to pursue this goal with you.

Emergency Contact Information: Name Address Phone Number. How did you hear about our office? Reason for your visit today?

Upperman Family Dental NEW PATIENT REGISTRATION

We Would Like to Get to Know You Better!

Patient Registration

A B O U T Y O U D E N T A L I N F O R M A T I O N

Married Single Widowed Legally Separated. Full Time Part-time Retired Not Employed Currently

Kids Dental Care Adult Patient Registration

Patient Name: Nickname: Date of Birth: Age: Sex: Male Female Address: City : Zip: School: Grade: Previous Dentist & Address: Pediatrician & Address:

Preferred Name: First Name: Last Name: Middle Initial: Home Phone: Work Phone: Ext: Cellular:

STEPHEN C. SNITZER, D.D.S.,

Welcome to South 40 Dental! Tell Us About Yourself

Access Endodontics Marat Tselnik, DDS -PRACTICE LIMITED TO ENDODONTICS-

Who is responsible for this account Relationship to patient. How did you hear about us (referral, facebook, etc.)?

Patient Registration. First Name: Last Name: Middle Initial: Address: City, State, Zip: First Name: Last Name: Middle Initial:

Sorina Ratchford DDS 747 Bernardo Ave. T:(805) Morro Bay Family Dentistry Morro Bay, CA F:(805) Page 1 /4

PATIENT REGISTRATION

COLVIN AVENUE DENTAL. Robert P. Vignali, DDS, PLLC 29 Colvin Avenue Albany, New York WELCOME LETTER. Dear

Calabasas Pediatric Dentisty & Orthodontics Patient Registration Form CONTACT INFORMATION

General Dental Treatment Consent Form

Medical Health Information (continued):

ANDERSON&HOFFNER DENTAL CENTER WELCOMES YOU!!!

Registration. Secondary Dental Insurance Subscriber s Name Date of Birth Social Security # Relationship to Patient Subscriber s Employer

Endodontic Associates of Alaska 800 E. Dimond Blvd. Ste Anchorage, AK 99515

Patient Registration. Additional Information. Insurance Information. Patient s Full Name: Date: Home Address:

Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:

Patient Medical and Dental History Personal Information. Name Date

Insurance Information

Welcome To Our Office

Patient Information. Address: Responsible Party/Insurance Policy Holder. (if someone other than patient) First Name: Last Name MI: Address:

RESPONSIBLE PARTY INFORMATION:

Highland Colony Dental- Donald K. Givan, DMD

REGISTRATION FORM / MEDICAl- DENTAL HISTOR. Telephone Number: _. Referred By: Family Members in the Practice: _. Preferred Tim e for Appointments:

Welcome to the office of

REGISTRATION FORM PATIENT INFORMATION. Patient s last name: First: Middle: Marital status: Occupation: Employer: Employer phone #: Physician name:

New Patient Information

If yes, please explain: Yes. If yes, please explain: Yes

Jennifer Unger Waters, D.D.S., P.C Washington Avenue Golden, CO (303)

PATIENT INFORMATION SCHOOL/LOCATION

New Patient Registration Form

MEDICAL HISTORY. PATIENT NAME Birth Date

PATIENT INFORMATION SHEET PERSON RESPONSIBLE FOR PAYMENT OF THIS ACCOUNT

PATIENT REGISTRATION

Last Name: First Name: Address: City: State: Zip: Home #: Work #: Mobile #: Gender: SS#: DOB: Marital Status: Employer:

How did you hear about our office?

PATIENT REGISTRATION INFORMATION DENTAL INSURANCE INFORMATION. Title:! Mr.! Mrs.! Ms.! Miss! Dr. Patient: Last Name: First Name: Middle:

Tuolumne Me-Wuk. Dental Clinic Greenley Road, Suite D Sonora CA Phone: Fax: Dear Patient,

TODAY S DATE FIRST MIDDLE LAST HOW YOU WOULD LIKE TO BE ADDRESSED? SOCIAL SECURITY #

GENERAL QUESTIONS CONTACT INFORMATION

PATIENT S NAME GENDER First Middle Init. Last Male/Female. Home Address. PATIENT EMPLOYER Bus. Phone. Employer Address. NAME OF SPOUSE Birth Date

Facebook. Jamboree Dentistry Website. Insurance. Mailer. Internet Search. Community Impact Newspaper Ad. Walk In. Online Appointment Request

Employment Information Patient Employed By: Occupation: Phone: Work Mailing Address:

David Palmieri, D.M.D., M.S., LTD., Frank R. Portell D.M.D.,M.S. & Nathan Schoenly, D.D.S. Please Check: Mr. Ms. Mrs. Dr. Fr. Sr. Hon.

Patient Name: Prefers to be called: Address: City: State: Zip: Home Phone: Cell Phone: Address: Birthdate: Age: Social Security Number:

WELCOME TO SANDIA DENTAL CARE

DENTAL QUESTIONNAIRE

MEDICAL AND PERSONAL HISTORY

NEW Adult Patient Information

Dental Patient Survey

Welcome to Dr. Halliday s Office

EMERGENCY INFORMATION Person to Contact: Relationship: Phone: Address:

New Patient Documentation. Name: (Last) (First) (Middle) Address: (Street) (Apt#) (City) (State) (Zip) Home Phone: ( ) Cell: ( ) Work: ( )

2053 Sidewinder Dr. Welcome to Our Office! Park City, Utah 84060

Welcome to Our Practice!

At any time you can schedule a free thirty minute consultation with Dr. Rabile to discuss your smile.

Patient Information:

Medical and Dental Health History Form Getting to Know You As Our Patient

Transcription:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES **You May Refuse to Sign This Acknowledgement** I,, have received a copy of this office s Notice of Privacy Practices. (Print Patient s Name) (Signature-Parent/Legal Guardian must sign if patient under 18) (Date) For Office Use Only We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because: Individual refused to sign Communications barriers prohibited obtaining the acknowledgement An emergency situation prevented us from obtaining acknowledgement Other (Please specify)

CONSENT FOR DENTAL TREATMENT Patient s Name: DOB: 1. I hereby authorize the Dentist at Ricard Family Dentistry and/or other such persons as he/she may appoint to perform any necessary dental; procedures as deemed appropriate as part of the dental treatment. 2. I understand that Dental treatment may include examination, prophylaxis, restorations, endodontics, x-rays, surgery and extractions for the purpose of maintaining, improving and/or restoring soft and hard tissue to a healthy state. 3. I hereby authorize and request dentists at Ricard Family Dentistry and/or such designees or assistants as may be selected by the doctor, to perform the following procedure as per dentists treatment plan. 4. I understand that the risks involved in the above described treatment or procedure(s) include but are not limited to bleeding, swelling, and sensitivity. 5. I understand that unforeseen conditions or circumstances may arise during the course of treatment: hence, I consent to and authorize the performance of any care, procedure or treatment not specified above that the dentist reasonably believes necessary or available as a result of unforeseen events. 6. Additionally, I consent to the administration of any local anesthetic that the dentist deems necessary. I understand that the risks involved with the administration of local anesthetics include but are not limited to: nerve injury, and stiffness of the jaw (trismus). 7. It has been explained to me the option of not using local anesthetic for my treatment. 8. I confirm that I have had the opportunity to ask any questions regarding the patient s care at the dental office and that all such questions (if any) have been answered fully and satisfactorily. 9. I certify that I have read this document and understand its contents. I acknowledge that dental treatment, associated risks and related dental education materials have been explained to my satisfaction. 10. This consent will remain in effect until I choose to terminate it. Dental and Medical History I certify that all of the preceding answers and information provided are true and correct to the best of my knowledge. I understand that the above information is necessary to provide me with dental care in a safe and efficient manner. I understand that providing incorrect information can be dangerous to my health. I have read and understand the above questions. I will not hold at Ricard Family Dentistry and its affiliated general dentists, and auxiliary staff responsible for any errors or omissions that I have made in the completion of this form. If there are any changes later to this history record or medical/dental status I will inform at Ricard Family Dentistry without fail. Assignment and Release I and/or my dependent(s) assign directly to Ricard Family Dentistry 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 Ricard Family Dentistry to release any information including the diagnosis and the records of any treatment or examination rendered to me or my dependents during the period of such dental care to third party payers and/or health practitioners for the purpose of obtaining payment and determining insurance benefits payable for related services. Consent for Services I understand and consent to have any treatment done by the dentist after the procedure, the risks, the benefits, and the costs have been fully explained. These treatments include, but are not limited to x-rays, cleanings, periodontal treatments, fillings, crowns, bridges, extractions, root canals, implants, and/or dentures. As a condition of your treatment by this office, financial arrangements must be made in advance. Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services. I understand that the fee estimates listed for this dental care can only be extended for a period of six months from the date of the patient examination. I grant my permission to you or your assignee to call me at home or at my work to discuss matters related to this form. I have read the above conditions of treatment and payment and agree to the content. I have read and understand the above: Date / / Patient/Representative Signature (Parent/Legal Guardian must sign if patient under 18) Dentist signature: Date / / Witness Date / / Telephone consent obtained from: Date / /

HEALTH HISTORY Patient Name Date / / Reason for today s visit? Please check every box if you have had any of the following: AIDS/HIV Epilepsy Radiation treatment Anemia Fainting or dizziness Respiratory disease Arthritis, Rheumatism Glaucoma Rheumatic fever Artificial heart valves Headaches Scarlet fever Artificial joints Heart murmur Shortness of breath Asthma Heart problems Sinus trouble Back problems Hepatitis? Type Skin rash Abnormal bleeding? Herpes Special diet Blood disease High blood pressure Stroke Cancer Jaundice Swollen feet or ankles Drug/Alcohol addiction Jaw pain Swollen neck glands Chemotherapy Kidney disease Thyroid problems Circulatory problems Liver disease Tonsillitis Congenital heart lesions Low blood pressure Tuberculosis Cortisone treatments Mitral valve prolapse Tumor or growth on head or neck Cough, persistent or bloody Nervous problems Ulcer Diabetes Pacemaker Venereal disease Emphysema Psychiatric care Weight loss, unexplained Allergies Are you allergic to any of the following? Local anesthetics Sulfa drugs Sedatives Iodine Any metals(nickel/mercury) Penicillin or other antibiotics Latex Other- Please describe Medications Please list all current medications and the correlating diagnosis: Women Only: Are you pregnant or think you may be pregnant? Y N Are you nursing? Y N Are you on birth control? Y N I certify that all of the preceding answers and information provided are true and correct to the best of my knowledge: Date / / Patient/Representative Signature (Parent/Legal Guardian must sign if patient under 18)

Welcome to Ricard Family Dentistry Registration Today s Date / / Name If Patient is under 18, Parent/Legal Guardian Name Home phone( ) Alt phone(cell/work) ( ) Address Apt # City State Zip Code Patient Date of birth : / / Sex: Female Male Single Married Soc. Sec # E Mail: @ In case of emergency call: Name Phone( ) Relationship to patient: Parent Guardian Friend Other: Insurance Info Do you have insurance? Yes No Subscriber Name Subscriber Social Security # Subscriber DOB / / Employer Phone( ) Name of Insurance Company Phone( ) ID# Plan Name Group # DENTAL HISTORY Former Dentist Phone( ) Date of last dental visit? / / Date of last dental x-ray? / / How often do you brush? How often do you floss? Physician Name Phone( ) Date of last visit? / / Pharmacy Name Phone( ) Please check every box if you have had any of the following: Bad breath Food collection between teeth Orthodontic treatment Bleeding gums Mouth pain, brushing Pain around ear Blisters on lips or mouth Grinding teeth Periodontal treatment Burning sensation on tongue Gums swollen or tender Sensitivity to cold Chew on one side of mouth Jaw pain or tiredness Sensitivity to heat Cigarette, pipe, or cigar smoking Lip or cheek biting Sensitivity to sweets Clicking or popping jaw Loose teeth or broken fillings Sensitivity when biting Dry mouth Mouth breathing Sores or growths in your mouth

Ricard Family Dentistry 1818 S.E. Port St. Lucie Blvd. Port St. Lucie, FL 34952 Office Financial Policy Payment is expected on the day service is provided. We offer a variety of payment options to help you receive the dental care needed to enjoy a healthy and confident smile. Regarding Dental Insurance Our office understands the value of insurance benefits to our patients. Your complete insurance information must be presented at the time services are provided. Insurance claims cannot be backdated. We accept most dental insurance plans and we will do all we can to assure you of maximum benefits. Once we confirm your dental coverage we will estimate your deductible and the portion that we feel will be covered by your insurance carrier, you will be asked to pay your estimated part of your bill at the time of your service. We will then file and submit to your insurance at no charge to you. After your insurance pays, any remaining balance will be billed to you. We cannot guarantee what your insurance company will pay, please be aware that some, and perhaps all, of the services provided may be non-covered services and not considered under the terms of your insurance policy. However, we can submit an insurance pre-estimate to your insurance company before any major work is done. Your insurance policy is a contract between you and your insurance company. We are not a party to that contract. In the event your insurance company has not paid your account in full within 90 days, the balance may be transferred to your account. Payment Options Cash/Checks/Debit: There will be a $35.00 fee for returned checks. Credit Cards: We accept most major credit cards. Care Credit: If you need help paying for procedures your insurance doesn t cover or want convenient monthly payment options with no up-front costs then CareCredit could be the answer for you. CareCredit gives you the freedom to get your procedure whenever you re ready. Upon credit approval we will be able start your treatment plan and you'll be on your way to a healthier smile. CareCredit is an outside source of revolving credit. It is similar to a conventional credit card, but its use is restricted to dental and medical services. You can apply for care credit at our office or online, it only takes a few minutes and there is no application fee. Most importantly, Care Credit offers you the opportunity to enjoy the benefits of dental health without the financial strain. Missed Appointments Once an appointment has been made, that time is reserved specifically for you. We reserve the right to charge a $25.00 for all canceled or missed appointments without 48-hours notice. Duplicate Records We will be glad to forward your records upon written request that should include the name and address of your chosen dentist. A minimum of 5 working days will be required for this service. Patients requesting their own copy will be charged a $17.00 fee to cover reproduction costs. Informed Consent for Routine Dental Treatment In order to provide comfortable dental treatment local anesthesia may be administered. Possible Complications include but are not limited to: Local pain/or infection Temporary but potentially permanent numbness or altered sensation to the nerve that goes to the lip, tongue, gum, etc Systemic (whole body reaction) including allergic reaction. Additionally, pain or prolonged discomfort to the jaw joints. Although usually temporary. We would be happy to discuss our charges and how they relate to your particular situation. We also realize that temporary financial situations may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account. Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns. I have read the Financial Policy. I understand and agree to this Financial Policy. Signature Date:

2024 © healthdocbox.com Privacy Policy | Terms of Service | Feedback