As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create. receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional  questions concerring your health. This information is vital to alow us to provide appropriate care for you, This office does not use this information to discriminate.

If you are completing this form for another person, what is your relationship to that person?

Do you have any of the following diseases or problems:

(Check DK if you Don't Know the answer to the question)

If you answer yes to any of the 4 items above, please stop and return this form to the receptionist

For the following questions, please mark (X) your responses to the following questions.

Dental Information

Medical information

please mark (X) your response to indicate if you have or have not had any of the following diseases or problems

WOMEN ONLY Are you:

Allergies. Are you allergic to or have you had a reaction to:

To all yes responses, specify type of reaction

Congenital heart disease (CHD)

Except for the conditionis listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD

NOTE: Both doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above  have been answered to my satisfaction I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form

FOR COMPLETION BY DENTIST

I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

* Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);

* Obtaining payment from third party payers (e.g. my insurance company);

* The day-to-day healthcare operations of your practice.

I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPPA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.

I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.

As a service to our patients, our practice welcomes all insurance plans provided by employers or a self-insured policy. We do ask that you please bring your insurance information to all of your appointments. We require that the deductible and co-payment portion, the amount not covered by your insurance company, be paid on the day of the services rendered. Our front desk will provide you with an estimate of benefits and prepare any necessary forms for your dental benefits.

For your convenience our office will submit claims on your behalf. Please remember that your insurance policy is a contract between you, your employer and your insurance company and it is your responsibility to understand the coverage and benefits being provided. Just as insurance companies do not allow us to set their premium rates, we do not allow them to set our fees or determine our procedures. We will do everything possible to provide you with accurate estimates and see that you receive full benefits of your policy. Please keep in mind that you are responsible for your insurance benefits if they result in less coverage than anticipated or your policy has changed. If you fail to update your new information with us, this will result in closing your insurance claim. We are happy to submit your dental claim to your insurance company 3 times, if the claim has not been paid after the final submission we will then proceed to close it. Upon closing the claim it becomes your financial responsibility to pay your account balance in full and seek reimbursement from your insurance company. We will provide you with all necessary documents to submit to your insurance company.

Your policy may base its allowances on a fixed fee schedule, which may or may not coincide with our fees. You should be aware that different insurance companies vary greatly in the types of coverage available. Also, some companies take care of claims promptly while others may delay payment for several months.

Our goal at Kenton Dental Care is to provide our patients with the highest quality dental care in a timely manner. In order to do so, we have had to implement an appointment/cancellation policy. This will enable us to utilize our available appointments for our patients in need of dental care.

In order to be respectful of the other patients, please be courteous and call promptly if you are unable to attend your scheduled appointment. This will allow us to offer that availability to someone who is in urgent need of treatment. If you find it necessary to cancel your scheduled appointment, we require that you call at least 24 hours in advance. Appointments are in high demand and this will allow us to give another patient the opportunity to have access to this available time. If you fail to notify us 24 hours prior to your appointment, then a cancellation fee may be applied to your account. If you fail ("no show") for your scheduled appointment, this is an inconvenience to those individuals who need access to dental care in a timely manner. This action will be recorded in your personal file and a fee of $50.00 will be applied to your account.

I have read the policy listed above and understand the consequences if either one of these situations occur.