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Claycomo Dental LLC

244 E US Highway 69,
Claycomo, MO 64119
(816) 454-1313

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
  •  Text
  •  Email
  •  Both
  •  Neither
( * mandatory to fill )
  •  Yes
  •  No
Responsible Party( * mandatory to fill )

I hereby give my consent to the dentist to perform an examination and diagnose my condition. I also give my consent for any preventative or basic restorative procedures which may be necessary. I understand that this consent will remain in effect until treatment is terminated either by me or the dentist.

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Primary Dental Insurance( * mandatory to fill )
  •  Yes
  •  No

Subscriber Information

Secondary Dental Insurance( * mandatory to fill )
  •  Yes
  •  No

Subscriber Information

Release of Information to Insurers and Assignment of Benefits( * mandatory to fill )

I certify that I, and/or my dependent(s), have insurance coverage and assign directly to Claycomo Dental LLC 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.

Claycomo Dental LLC may use my health care information and may disclose such submission to my insurance company and its agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.

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Dental History( * mandatory to fill )
  •  last 6 months
  •  6 months -1 year
  •  1-3 years
  •  Greater than 4 years
  •  Never
  •  last 6 months
  •  6 months -1 year
  •  1-3 years
  •  Greater than 4 years
  •  Never
  •  Yes
  •  No
  •  Yes
  •  No

Oral Health

  •  Check-Up
  •  Cleaning
  •  Toothache
  •  Broken Tooth
  •  Cosmetic
  •  Implants
  •  Other
  •  Yes
  •  No
  •  once a day
  •  twice a day
  •  a few times a week
  •  rarely or never
  •  once a day
  •  twice a day
  •  a few times a week
  •  rarely or never
  •  Yes
  •  No
  •  1
  •  2
  •  3
  •  4
  •  5
  •  6
  •  7
  •  8
  •  9
  •  10
  •  Pain in Jaw
  •  Clicking
  •  Sensitive Teeth
  •  Smoke/Vape
  •  Teeth Grinding/Clenching
  •  Popping
  •  Broken/Loose Teeth
  •  Controlled Substances
  •  Bad Breath
  •  TMD/TMJ
  •  Difficulty Chewing
  •  Chew Tobacco
  •  Mouth Sores
  •  Dry Mouth
  •  Swollen/Bleeding Gums
  •  Wear dentures/partials

Sleep Health

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

Women Patients Only

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

**NOTE** Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control

HEALTH HISTORY( * mandatory to fill )

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.

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  1 -3 years
  •  6 months - 1 year
  •  Greater than 4 years
  •  Last 6 months
  •  Never
  •  Acrylic
  •  Aspirin
  •  Codeine
  •  Iodine
  •  Latex
  •  Local Anesthetic
  •  Metals
  •  No known allergies
  •  Penicillin
  •  Sleeping pills
  •  Sulfa drugs
  •  Other?

Do you have, or have you had, any of the following?

  •  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
  •  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
  •  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
  •  Yes
  •  No

To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and/or medication. I further certify that I consent to taking xrays and an oral examination.

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Notice of Privacy Practices( * mandatory to fill )

Purpose of Consent: By signing this form you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read the Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices including any revisions of our Notice at any time by contacting

Contact Person: Karen Mychalczuk
Telephone: 816-454-1313
Fax: 816-454-5377
Address: 244 E US Highway 69, Suite 101, Claycomo, MO 64119

Consent

By signing below, I acknowledge I have had full opportunity to read and consider the contents of the Privacy Practices. I understand that, by signing this form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations.

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Right to Revoke: You have the right to revoke this consent at any time by giving us written notice of your revocation submitted to Claycomo Dental. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation and that we may decline to treat you or to continue treating you if revoke this Consent.

Office Policies( * mandatory to fill )

Thank you for selecting us as your dental health care provider. Our goal is to provide you and your family with optimal dental care. We want you to feel welcome and as comfortable as possible throughout our relationship. We encourage you to ask questions and to be involved in treatment decisions. Your understanding of our policies is an essential element of your care and service.

- We require ONE (1) business day to cancel or reschedule an appointment:

Patients that cancel without a 24-hour notice or no show will be charged a cancellation fee of $25.00. No future appointments can be scheduled nor can records be transferred without the payment of this fee. Habitual missed appointments are grounds for dismissal from the practice.

- Appointments over 90 minutes and/or Double-booking (1 appt with hygiene and 1 appt with the Doctor) Require(s) a $50.00 deposit:

Our staff and doctors devote an extensive amount of time to preparing and reserving uninterrupted time for you. Appointments over 90 minutes and/or two appointment reservations for the same patient on the same day require a $50.00 deposit. The deposit will be applied to the payment due or refunded on the day of the completed appointment(s). The deposit must be paid at the time of scheduling. In the case of a failed or canceled an appointment with less than 48 hours-notice the $50.00 fee is non-refundable.

- Payment for services is due at the time services are rendered:

Your estimated portion is due at the time service is rendered. There are times when an insurance company will pay more than expected. Refunds will be processed within 4 to 6 weeks. Any money owed to the patient under the amount of $20.00 will be left as a credit on the account. If your credit is over $20.00, how would you prefer it be handled?

  •  left on your account
  •  refunded via mailed check

- We will bill your insurance benefits for payment:

We are happy to file insurance for you but please be aware that any portion not paid by your insurance will be your responsibility. We contact your insurance company prior to your appointment to verify the benefits and to obtain a general benefits breakdown. We will give you an estimate for any proposed treatment however it is your responsibility to be familiar with your dental plan. We are not responsible for any discrepancies between our estimate and the actual payment from your insurance company.

If your insurance has not paid within 90 days of services rendered, your claim will be closed and the remaining balance will automatically become patient responsibility. The insured has a better ability to deal with the insurance company and the employer responsible for the policy.

Cancellation, Extended Appointments, and Financial Arrangement Policies

By signing below, I acknowledge that I have read and understood the Office Policies, and further, I agree to accept these terms.

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Release of Health Records( * mandatory to fill )

Authorization for Release of Health Records to External Parties

  •  Yes
  •  No

I authorize the disclosure of information from my treatment records to:

  •  All treatment information
  •  Information specifically related to these treatment dates
  •  All treatment information
  •  Information specifically related to these treatment dates
  •  All treatment information
  •  Information specifically related to these treatment dates
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Authorization & Release( * mandatory to fill )

I, the undersigned, certify that I (or my dependent) have insurance coverage and assign directly to Claycomo Dental 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 hereby authorize the doctor to release all information necessary to secure the payments of benefits. I authorize the use of this signature on all insurance submissions.

Consent

I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care.

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