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Patient Registration Form

High Desert Dental

12212 W AMITY RD,
Boise, ID 83709
2083434732

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
  •  Text
  •  E-mail
  •  Text & E-mail
  •  Phone Call

Patient or Parent Phone Numbers

Emergency Contact Information( * mandatory to fill )
( * mandatory to fill )
Primary Dental Insurance( * mandatory to fill )
  •  Yes
  •  No
Referral Information( * mandatory to fill )
  •  Our Website
  •  Google
  •  Facebook
  •  Location
  •  Promotion
  •  Insurance Company
  •  Patient
  •  Other
Secondary Dental Insurance( * mandatory to fill )
Patient Medical History( * mandatory to fill )
  •  Yes
  •  No

MEDICATIONS 

Note: If a larger list, give a paper copy to front desk.

  •  Yes
  •  No
  •  Pregnant
  •  Trying to get pregnant
  •  Nursing
  •  Taking oral contraceptives

Allergies

 Are you allergic to any of the following?

  •  Aspirin
  •  Acrylic
  •  Amoxicillin
  •  Codeine
  •  Metal
  •  Penicillin
  •  Local Anesthetics
  •  Latex
  •  Other

Do you currently have, or have you ever had, any of the following conditions?

  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Is Premed Needed
  •  Date of Replacement
  •  Name of Surgeon
  •  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
  •  2 times a Day
  •  Once a Day
  •  Weekly
  •  Seldom
  •  Soft
  •  Medium
  •  Hard
  •  Electric
  •  Sonicare
  •  Oral B
  •  1 time a day
  •  2 times a day
  •  2-4 times a week
  •  1-6 months times a month
  •  Seldom
  •  Never
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No

To the best of my knowledge, all of the preceding information is true and correct. If I ever have a change in my health, I will inform the office at my next dental appointment without fail.

I hereby certify that I have read and understand the previous information and that it is accurate and true to the best of my knowledge.

I acknowledge that providing incorrect and/or inaccurate information has the potential of being hazardous to my health.

 

I authorize the diagnosis of my dental health by means of radiographs, study models, photographs, or other diagnostic aids deemed appropriate.

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FINANCIAL POLICY( * mandatory to fill )

At High Desert Dental, our ultimate goal is your dental health and wellness. That's why we always present you with the best dental solutions possible to treat your personal situation. Each year we provide outstanding dental care to hundreds of patients. Some have dental insurance benefits but some do not. If you have dental benefits congratulations! You are extremely fortunate. Here are some important points you should know:

Your dental benefits are based upon a contract made between you, your employer and your insurance. If you have any questions regarding your dental benefits please contact your employer or insurance company directly. Dental insurance plan pay for a percentage of your treatment needs and you are responsible for the remainder.

We currently accept a large number of PPO insurance plans. Although we can maintain computerized histories of payments by a given company, they do change; therefore it is impossible to give you a guaranteed quote at the time of service. We estimate your portion based on the most up-to-date information we have but it is ONLY AN ESTIMATE. If you would like exact out of pocket figures, we can submit a “pretreatment authorization” with your insurance company. Keep in mind this is not a guarantee of coverage and it may delay treatment.

We will bill your insurance company as a courtesy. If insurance does not pay within 90 days, High Desert Dental reserves the right to request payment in full for services from you and let you collect the insurance funds due to you. This is rare, but it is important that you recognize that the insurance you have is a legal contract between YOU and your insurance company. Our office is not, and cannot be a part of that legal contract. Ultimately, you are responsible for all charges incurred in our office.

High Desert Dental does require payment in full for your portion at the time of service. We accept MasterCard, Visa, American Express, Discover, cash, and checks. If you are in need of payment plans, we also work with CareCredit which offers 6 or 12 months “same as cash" no interest financing. Our staff can assist you in the application process.

A specific amount of time is reserved especially for you and we strongly encourage all patients to keep their appointments. If you must change your appointment, we require at least 24 hours notice to avoid a $20 cancellation fee.

I have read and agree with the above conditions.

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Patient Record Release( * mandatory to fill )

I request that my dental records and x-rays are transferred to High Desert Dental Please email x-rays to drmatt@cableone.net

Please email x-rays to drmatt@cableone.net

Offices, please note the date x rays were taken for our records.

 

Please Contact High Desert Dental at 208-343-4732 if you have any questions.

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Notice of Privacy Practices( * mandatory to fill )

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I HAVE CERTAIN RIGHTS TO PRIVACY REGARDING MY PROTECTED HEALTH INFORMATION. I UNDERSTAND THAT THIS INFORMATION CAN AND WILL BE USED TO:

 * CONDUCT, PLAN AND DIRECT MY TREATMENT AND FOLLOWUP AMONG THE MULTIPLE HEALTHCARE PROVIDERS WHO MAY BE INVOLVED IN THAT TREATMENT DIRECTLY AND INDIRECTLY.

* OBTAIN PAYMENT FROM THIRD-PARTY PLAYERS

* CONDUCT NORMAL HEALTHCARE OPERATIONS SUCH AS QUALITY ASSESSMENTS AND PHYSICAIAN CERTIFICATIONS

I have been informed by you and 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 from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices

High Desert Dental

12212 W. Amity Road

Boise, ID 83709

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 health care operations. I also understand you are not required to agree to my request for restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

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