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Patient Registration Form

Apex Endodontics, LLC Westfield

214 St. Paul Street,
Westfield, NJ 07090
9082335588

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
medical history( * mandatory to fill )

1. Do you have (or have you had) any of the following diseases or problems?

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

All questions have been answered accurately to the best of my knowledge.

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Authorization and Consent( * mandatory to fill )

To Send Unencrypted Patient Information by Email and Other Electronic Means

Until I tell you in writing to stop, I authorize Apex Endodontics, LLC to transmit patient information relating to my treatment, health, or payment by email or other electronic means, without encryption or special security precautions, to me or someone I designate, or to other health care providers, health plans and others involved in my treatment, payment for my treatment, or Apex Endodontics, LLC health care operations. The patient information that may be emailed may include my x-rays, health history, diagnosis, treatment, and payment records.

I understand that:

* I do not have to sign this form.

* My treatment, payment, enrollment and eligibility for benefits will not be affected by my decision about signing this form.

* If I don't sign this form Apex Endodontics, LLC may use other ways to send my information, such as U.S. Mail, or may ask me to send my information to third parties myself.

* There is some risk that emails and other electronic messages may be improperly acquired by hackers or received by unintended recipients. If that happens, the information may be re-disclosed and no longer protected by privacy law,

* Apex Endodontics, LLC does not email such sensitive personal information as Social Security number, credit card number, mental health diagnosis, genetic information, alcohol/substance abuse, or positive HIV status unless the patient insists.

I can tell you in writing to stop emailing my patient information at any time, but if I do so, this will not affect emails that Apex Endodontics, LLC already sent before receiving my written instructions to stop.

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Dental Team: Give a copy of this signed form to the patient. Save the original in the patient's file.

Authorization to Release Information( * mandatory to fill )

I hereby authorize Apex Endodontics, LLC to provide any insurance company(s). claim administrator(s) and consulting health care professionals information concerning health care, advice, treatment or supplies provided.

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IN ORDER TO AVOID OUR $175 MISSED APPOINTMENT FEE, WE MUST HAVE 48 HOURS NOTICE ON ALL APPOINTMENT CHANGES.

HIPAA Omnibus Rule( * mandatory to fill )

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT/ LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgment & authorization. In refusing we may not be allowed to process your insurance claim.

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITYS IN THE FUTURE.

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  •  First Name Only
  •  Proper Sur Name
  •  Other

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:

(This includes step parents, grandparents and any care takers who can have access to this patient's records):

I AUTHORIZE CONTACT FROM THIS OFFICE TO CONFIRM MY APPOINTMENTS, TREATMENT & BILLING INFORMATION VIA:

  •  Cell Phone Confirmation
  •  Home Phone Confirmation
  •  Work Phone Confirmation
  •  Text Message to my Cell Phone
  •  Email Confirmation
  •  Any of the Above

I AUTHORIZE INFORMATION ABOUT MY HEALTH BE CONVEYED VIA:

  •  Cell Phone Confirmation
  •  Text Message to my Cell Phone
  •  Home Phone Confirmation
  •  Email Confirmation
  •  Work Phone Confirmation
  •  Any of the Above

I APPROVE BEING CONTACTED ABOUT SPECIAL SERVICES, EVENTS, FUND RAISING EFFORTS OF NEW HEALTH INFO on behalf of this Healthcare Facility via:

  •  Phone Message
  •  Text Message
  •  Email
  •  Any of the Above
  •  None of the above (opt out)

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from there affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent

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Informed Consent for Endodontic Procedures( * mandatory to fill )

1. Recommended Treatment

I hereby give consent to Harout Barsemina, DMD to perform Endodontic Procedures procedure(s) on me or my dependent as follows:

("Recommended Treatment") and any such additional procedure(s) as may be considered necessary for my well being based on findings made during the course of the Recommended Treatment. The nature and purpose of the recommended Treatment have been explained to me and no guarantee has been made or implied as to result or cure. I have been given satisfactory answers to all of my questions, and I wish to proceed with the Recommended Treatment. I also consent to the administration of local anesthesia during the performance of the Recommended Treatment.

II. Discussion of Treatment

The Recommended Treatment works by removing bacteria from the hollow space inside the tooth, and by sealing off the inside of the tooth to prevent re-infection. Although the Recommended Treatment has a very high success rate, it is a biological procedure and cannot be guaranteed. Occasionally, a tooth which has had root canal treatment may require retreatment, additional surgery, or extraction.

III.Treatment

Alternative methods of treatment have been explained to me, such as extraction of the involved teeth, or postponement of root canal therapy, but I wish to proceed with the Recommended Treatment described above.

IV. Risks and Complications

I understand that there are risks and complications associated with the administration of medications, including anesthesia, and performance of the Recommended Treatment.

These potential risks and complications, include, but are not limited to, the following:

1. Instrument breakage in the root canal.

2. Inability to negotiate canals due to prior treatment or calcification.

3. Perforation to the outside of the tooth.

4. Irreparable damage to the existing crown or restoration.

5. Cracking or fracturing of the root or crown of the tooth.

6. Pain, infection and swelling.

7. Difficulty opening and closing.

8. Temporomandibular Dysfunction resulting in jaw pain.

9. Nerve injury resulting in temporary or permanent numbness, itching, burning or tingling of the lip, chin, tongue or teeth.

10. As a result of the injection or use of anesthesia, there may be swelling, jaw muscle tenderness or even resultant numbness of the tongue, lips, teeth, jaws and/or facial tissues, which is typically temporary, but in rare instances, may be permanent.

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