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Prairie Dental Group

6608 Flying Cloud Drive,
Eden Prairie, MN, 55344
(952) 903-5000

Patient Details( * mandatory to fill )

WELCOME! Our goal is to help you have the healthiest, brightest smile possible. Please provide the following information as completely as you can. The better we communicate, the better we can care for your dental needs.

  •  email/text
  •  phone call only
  •  email only
  •  text only
Contact Information( * mandatory to fill )
Account Information( * mandatory to fill )
( * mandatory to fill )
Please Select below( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
Primary Dental Insurance( * mandatory to fill )

I authorize the administration of such medications and performance of such diagnostic and therapeutic procedures as may be necessary for proper dental care. If additional information is needed, I authorize this office to contact the appropriate health care provider or agency to obtain such information. I understand that dental insurance is a contract between the policyholder and the insurance carrier, and that I am responsible for payment of fees for services not covered in part or in whole by the insurance carrier. I authorize payment of dental insurance benefits directly to this office. The above information is correct to the best of my knowledge. Charges may be assessed if less than 48 hours notice or no notice is given when an appointment cannot be kept.

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Secondary Dental Insurance( * mandatory to fill )

I authorize the administration of such medications and performance of such diagnostic and therapeutic procedures as may be necessary for proper dental care. If additional information is needed, I authorize this office to contact the appropriate health care provider or agency to obtain such information. I understand that dental insurance is a contract between the policyholder and the insurance carrier, and that I am responsible for payment of fees for services not covered in part or in whole by the insurance carrier. I authorize payment of dental insurance benefits directly to this office. The above information is correct to the best of my knowledge. Charges may be assessed if less than 48 hours notice or no notice is given when an appointment cannot be kept.

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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
  •  No
  •  Yes
  •  No
  •  Yes
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  •  No
  •  Aspirin/Ibuprofen
  •  Codeine
  •  Cephalosporins
  •  Food Allergy
  •  Latex
  •  Local Anesthetics
  •  Metal or Acrylic
  •  Penicillin/Amoxicillin
  •  Sulfa drugs
  •  Seasonal
  •  Other Allergies
  •  No Known Allergies
Medical History( * mandatory to fill )

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

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  •  No
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*The American Heart Association or American Academy of Orthopaedic Surgeons may suggest taking antibiotics prior to dental treatment.

  •  Yes
  •  No

The questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform Prairie Dental Group of any changes in medical status.

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MEDICATIONS( * 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.

Please list your medications, include both prescribed and over the counter.

  •  Click here if taking No medications.

To the best of my knowledge, the medications on this list are accurate. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental office of any medication changes.

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Dental History / Cavity Risk Factors( * mandatory to fill )
  •  Excellent
  •  Good
  •  Fair
  •  Poor
  •  Yes
  •  No
  •  Yes
  •  No
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  •  No
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  •  Invisalign/Orthodontics
  •  Cosmetic Dentistry
  •  Cavity Prevention/Sealants
  •  Whitening
  •  Night/Sport Guards
  •  Sedation Dentistry
  •  Dental Implants
  •  Sleep Apnea Prevention
Consent for Use and Disclosure of Health Information( * mandatory to fill )

To the Patient – PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY:

Purpose of Consent: By signing this, 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 is available upon request. 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:

 

Contact Officer
Caryl Leach
6608 Flying Cloud Drive
Suite 200
Eden Prairie, MN 55344
952-903-5000 FAX 952-944-0642
Carylleach@prairiedental.com

 

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.

CONSENT FOR USE AND DISCLOSURE:

I am aware this consent will remain in effect as long as I am a patient of record. 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 heath care operations.

IF THIS CONSENT IS SIGNED BY A PERSONAL REPRESENTATIVE ON BEHALF OF THE PATIENT, COMPLETE THE FOLLOWING:

  

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Authorization/Request for Dental Images( * mandatory to fill )

Please forward these images:   Panorex/Full Series less than 5 years old

                                                  Bitewings less than 2 years old



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