(Note: we are a non-participating practice and therefore do not accept any dental insurance.  All payments are due as service is rendered)

For the following questions, select yes or no, whichever applies.  Your answers are for our records only and will be considered confidential.  Please note that during your initial visit you may be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

Health History

9. Do you have or have you had any of the following diseases or problems?

b. Cardiovascular disease (heart trouble, heart attack, angina, coronary insufficiency, coronary occlusion, high blood pressure,arteriosclerosis, stroke?----(select applicable conditions)

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

Women

Dental History

By signing below, I acknowledge that I have completed the above information to the best of my knowledge.  Additionally, I will not hold my dentist or any other member of his staff responsible for any errors or omissions that I have made in the completion of this form.

For completion by the dentist.

Medical history update

Office Policies

I hereby authorize Dr. Neil Starr and his team to release any and all medical and dental information pertinent to my treatment to the above named insurance carrier(s) for the purposes of pre-authorization of treatment plan and fees, claims processing, utilization review or financial audit.  I have been informed that this office will report my diagnosis, treatment and fees to my carrier(s) in accord with standards conforming to the current procedures established by the American Dental Association and that it is the sole responsibility of my carrier(s) to determine the actual dollar amounts of benefits for all services rendered.  I understand that I am ultimately responsible for the total costs of my treatment provided by Dr. Neil Starr and his team. 

Privacy of Information Policy:

I have been informed that this practice will make reasonable efforts to protect the privacy of my health information in accord with the policies set down for dental care providers under the Health Insurance Protection and Accountability Act of 1996 and have read this practice’s policy statement on privacy of patient’s healthcare information.  I authorize the release of any and all medical and dental information pertinent to my treatment to my other treating healthcare providers.

Cancellation Policy:

So that we may maintain the operation of our office on sound principles and to assure you and other patients of uninterrupted treatment, it is necessary for all patients to accept and adhere to a definitive arrangement of appointments and fees.  Once you have made an appointment, remember this time is reserved for you, therefore, at lease 48 hours notice must be given if cancellation is absolutely necessary, otherwise a usual fee charge of $225 will be made.

Payment:

I understand that payment is due as service is rendered regardless of insurance coverage.  (The office currently accepts payment by check, Visa, MasterCard, American Express, or Discover)

Notice of Privacy Practices:  (you may refuse to sign this Acknowledgement)

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me.  I have been given the opportunity to ask any questions I may have regarding this notice.

The above statements and policies and that this authorization remains valid and effective from the date of signing until revoked in writing.

HIPAA Designation of Personal Representative

You may designate a personal representative who may act in your behalf in making decisions relating to health care, which includes treatment and payment issues. This individual can be  family member, friend, lawyer or unrelated party.

I authorize  Neil L Starr DDS, PC to release information relating to the care and payment for

To