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Patient Registration Form.

Lake Family Dental

301 State Ave SW,
Warroad, MN, 56763
(218) 386-1048

Patient Information( * mandatory to fill )
Emergency Contact Information( * mandatory to fill )
RELATIVE NOT LIVING WITH YOU( * mandatory to fill )
PERSON FINANCIALLY RESPONSIBLE FOR THIS ACCOUNT( * mandatory to fill )
Primary Dental Insurance ( * mandatory to fill )
SECONDARY DENTAL INSURANCE [IF ANY] ( * mandatory to fill )
CONSENT TO TREAT( * mandatory to fill )
  1. I hereby authorize the attending doctor(s) or designated team members to take x-rays, study models, photographs, and any other diagnostic aids deemed appropriate to make a thorough diagnosis of patient's dental needs.

  2. Upon such diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.

  3. I consent to the use of appropriate medication and therapy as deemed necessary. I fully understand that using anesthetic agents embody a certain risk. 

  4. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by an agreed upon date(s), I understand that a 1 1/2% finance charge (18% APR) may be added to my account. I further understand that I am responsible to pay reasonable attorney’s fees and all costs of collection in the event of my default.

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AUTHORIZATION FOR SUBMISSION OF CLAIMS AND ASSIGNMENT OF BENEFITS( * mandatory to fill )

I authorize the health care provider to submit claims for payment for services to the health care service plans or insurance companies named, on my behalf and in my name, and assign to such provider the group insurance benefits otherwise payable to me, not to exceed the provider's actual charges for the covered services. I understand that I am financially responsible for any charges not covered by the group insurance benefits.

I authorize the health care provider to release to hospital or health care service plans, insurance companies, self-insurers, or their representatives, any and all information and records (including x-rays) about my medical history, or about services rendered or treatment given to me, that is needed to review, investigate or evaluate any claim for benefits. If my coverage is under a group master agreement held by my employer, and association, trust fund, union or similar entity, this authorization also permits disclosure to them for purposes of utilization review or financial audit. This authorization shall remain effective for up to five years from this date. I know that I have the right to receive a copy of this authorization if requested.

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Medical 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
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  •  Pregnant/trying to get pregnant
  •  Nursing
  •  Taking oral contraceptives
  •  Aspirin
  •  Pencillin
  •  Codeine
  •  Acrylic
  •  metal
  •  Latex
  •  sulfa drugs
  •  Local anesthetics

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

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DENTAL HISTORY( * mandatory to fill )
  •  Exam and X-rays only
  •  Emergency work only (e.g. Toothache)
  •  Replacement of missing or damaged teeth (e.g. crowns, veneers, dentures, partials, implants)
  •  Thorough evaluation of all dental needs
  •  Orthodontic Consult
  •  Other

Do you now or have you ever had: (Please check Yes or No to the following questions. Give dates, if known)

  •  Yes
  •  No
  •  Yes
  •  No
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  •  Cigarettes
  •  Cigars
  •  Pipe
  •  Smokeless tobacco
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
  •  Yes
  •  No
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CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION( * mandatory to fill )

SECTION A: PATIENT GIVING CONSENT

SECTION B: TO THE PATIENT PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

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 our 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, which will contain the changes. 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:

Kathy Thiele, Office Manager 1(218) 386-1048
1(218) 386-1049 (FAX)
PO Box 490 Warroad, MN 56763 lakefamilydental@mncable.net

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. 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 you revoke this Consent.

SIGNATURE

I, 

have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent 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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(Your IP Address : IP:34.236.153.51 )

 

If this Consent is signed by a personal representative on behalf of the patient, complete the following:

 

YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT.

Include completed Consent in the patient’s chart.

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