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New Patient Form

Newbury Dental

1443 Leimert Boulevard,
Oakland, CA 94602
5104825300

Patient Information( * mandatory to fill )

Welcome to our office. We appreciate the confidence you place with us to provide dental services. To assist us in serving you, please complete the following form. The information provided on this form is important to your dental health. If there have been any changes in your health, please tell us. If you have any questions, don't hesitate to ask.

Patient Information( * mandatory to fill )
  •  Delta Dental
  •  Cigna
  •  Sun Life
  •  Walking/Driving By
  •  Living in Neighborhood
  •  Google
  •  Facebook
  •  Twitter
  •  Mailer
  •  Concierge Ad/Brochure
  •  Existing Patient
  •  Donation Drive
  •  Aetna
  •  Guardian
  •  Metlife
  •  Mailer
  •  Other
Dental History( * mandatory to fill )
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Do you feel twinges of pain when your teeth come in contact with

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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.

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  •  Pregnant/trying to get pregnant?
  •  Nursing?
  •  Taking oral contraceptives?
  •  Aspirin
  •  Pencillin
  •  Codeine
  •  Acrylic
  •  metal
  •  Latex
  •  sulfa drugs
  •  Local anesthetics
  •  Other
Do you have, or have you had, any of the following?
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  •  No
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To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or my patient) health. It is my responsibility to inform the dental office of any changes in medical status.

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General Consent to Dental Treatment at Newbury Dental( * mandatory to fill )

I consent to be a patient at the above-named office in Oakland, California and agree to a radiographic (x-rays) examination, a clinical dental examination and prophy (dental cleaning). I also understand and consent to the following:

1. During the course of treatment, I may undergo procedures in all phases of dentistry including periodontics (gum treatment and surgery), oral surgery, endodontics (root canals), fixed and removable prosthodontics (crowns, bridges, and dentures), implant dentistry, restorative dentistry, temporomandibular disorder treatment, sleep apnea treatment, oral pathology, pediatric dentistry, and radiography. I acknowledge that Newbury Dental associates and employees will make every effort to explain the nature and purpose of proposed procedures and alternative options, but it is the patient responsibility to ask questions and elect for treatment.

2. Once I am informed of recommended treatments and agree to undertake them, I authorize the dentists, hygienists and dental assistants at Newbury Dental to perform those procedures as may be deemed necessary or advisable to maintain my dental health or the dental health of any minor or other individual for which I have legal responsibility, including arrangement and/or administration of any sedative (including nitrous oxide), analgesic, therapeutic, and/or other pharmaceutical or chemical agent(s), including those related to restorative, palliative, therapeutic or surgical treatments.

3. I voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with general preventative and operative treatment procedures in hopes of obtaining the potential desired results which may or may not be achieved for my benefit or the benefit of my minor child or ward. I understand that any branch of medicine, including dentistry, can involve unanticipated results.

4. I have the right to refuse any specific dental treatment, and I voluntarily assume any and all possible risks, including the risk of substantial and serious harm, if any, which may be associated with foregoing any dental diagnostic or recommended treatment procedure.

5. I understand that the administration of local anesthetic may cause an untoward reaction or side effects, which may include, but are not limited to bruising, hematoma, cardiac stimulation, and temporary or rarely, permanent numbness, and muscle soreness. I understand that it is possible for needles to break during the administration of local anesthetic and that surgical recovery of the needle may be necessary.

6. I am welcome to ask questions about any aspects of my dental care and will request information if I am confused or need more information. I am responsible for clarifying any aspects of my treatment that I am unsure about. 

7. I understand that Newbury Dental requests 48 hours notice for canceling any appointment. If I dont notify Newbury Dental of a cancellation at least 48 hours in advance of the appointment, I will be subject to a $75 appointment cancellation fee. If procedures performed during an appointment cost more than $4,000, I agree to paying a 10% down payment for those procedures, at the time of booking of that appointment. 

8. Payment may be made in cash, check, or by credit card. I understand that my balance for services is due on the day the treatment is rendered. If I am an insured patient, I am responsible for the patient portion of the contracted insurance fees on the day the treatment is rendered as well. The amount of reimbursement is determined by the insurance carrier and the numbers I am presented on the day of treatment are estimates. If the final reimbursement or patient responsibility amounts change, I may be responsible for additional payment to Newbury Dental. If financing is offered and accepted by me through a third party or through Newbury Dental, I am subject to the terms of the financing agreement and will make payments to Newbury Dental or the third party in accordance and at the times specified in the agreement. A $25 processing fee will be charged for a returned check. 

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HIPAA Information and Consent Form( * mandatory to fill )

The Health Insurance Portability and Accountability Act (HIPAA) provides safeguards to protect your privacy. Implementation of HIPAA requirements officially began on April 14, 2003. Many of the policies have been our practice for years. This form is a "friendly" version. A more complete text is posted in the office.

What this is all about: Specifically, there are rules and restrictions on who may see or be notified of your Protected Health Information (PHI). These restrictions do not include the normal interchange of information necessary to provide you with office services. HIPAA provides certain rights and protections to you as the patient. We balance these needs with our goal of providing you with quality professional service and care. Additional information is available from the U.S. Department of Health and Human Services. www.hhs.gov

We have adopted the following policies:

  1. Patient information will be kept confidential except as is necessary to provide services or to ensure that all administrative matters related to your care are handled appropriately. This specifically includes the sharing of information with other healthcare providers, laboratories, health insurance payers as is necessary and appropriate for your care. Patient files may be stored in open file racks and will not contain any coding which identifies a patient's condition or information which is not already a matter of public record. The normal course of providing care means that such records may be left, at least temporarily, in administrative areas such as the front office, examination room, etc. Those records will not be available to persons other than office staff. You agree to the normal procedures utilized within the office for the handling of charts, patient records, PHI, and other documents or information.
  2. It is the policy of this office to remind patients of their appointments. We may do this by telephone, e-mail, U.S mail, or by any means convenient for the practice and/or as requested by you. We may send you other communications informing you of changes to office policy and new technology that you might find valuable or informative.
  3. The practice utilizes a number of vendors in the conduct of business. These vendors may have access to PHI but must agree to abide by the confidentiality rules of HIPAA.
  4. You understand and agree to inspections of the office and review of documents which may include PHI by government agencies or insurance payers in the normal performance of their duties.
  5. You agree to bring any concerns or complaints regarding privacy to the attention of the office manager or the doctor.
  6. Your confidential information will not be used for the purposes of marketing or advertising of products, goods or services.
  7. We agree to provide patients with access to their records in accordance with state and federal laws.
  8. We may change, add, delete or modify any of these provisions to better serve the needs of both the practice and the patient.
  9. You have the right to request restrictions in the use of your protected health information and to request change in certain policies used within the office concerning your PHI. However, we are not obligated to alter internal policies to conform to your request.

I, 

on this date 

 do hereby consent and acknowledge my agreement to the terms set forth in the HIPAA INFORMATION FORM and any subsequent changes in office policy. I understand that this consent shall remain in force from this time forward.

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