NEW PATIENT FORMS Patient Information Form

WELCOME TO OUR PRACTICE

  •  Cell phone/Text
  •  Email
  •  Home Phone
  •  Leave a message

DENTAL INFORMATION

  •  Excellent
  •  Good
  •  Fair
  •  Poor
  •  3 mos
  •  4 mos
  •  6 mos
  •  12 mos
  •  Not routinely
  •  Complications from past dental treatment
  •  Reactions to local anesthetic
  •  Experiences dry mouth
  •  Food gets trapped between teeth
  •  Popping and/or clicking of your jaw joint
  •  Clenching or grinding of teeth
  •  Wears removable partial/denture
  •  Diagnosed and/or treated for gum disease
  •  Noticed an unpleasant taste or odor in your mouth
  •  Teeth become loose on their own (without injury)
  •  Trouble getting numb
  •  Past/Present braces or orthodontic treatment
  •  Sensitive to hot, cold, biting, sweets
  •  Whitened or bleached your teeth
  •  Difficulty chewing
  •  Currently or previously wore a bite appliance
  •  Gums bleed when brushing or flossing
  •  Bone loss around your teeth
  •  Experienced gum recession
  •  Snores or wakes up frequently during the night

CONSENT FOR INTERNET COMMUNICATIONS

I grant my permission to the dental practice to upload and store confidential patient information (including account information, appointment information and clinical information) to the secured web site for the dental practice. I understand that, for security purposes, the site requires a user ID and password for access and use. I also understand the dental practice and I are responsible for maintaining the strict confidentiality of any ID and password assigned to me; and that the dental practice is not liable for any charges, damages, or losses that may be incurred or suffered as a result of my failure to maintain confidentiality. I understand the dental practice is not liable for any harm related to the theft of my ID and password, my disclosure of my ID and password, or my authorization to allow another person or entity to access and use the dental practice web site with my ID and password. I also agree to immediately notify the dental practice of any unauthorized use of my ID or of any other need to deactivate my ID due to security concerns.

 

I also understand that State and Federal laws, as well as ethical and licensure requirements impose obligations with respect to patient confidentiality that limit the ability to make use of certain services or to transmit certain information to third parties. I understand the dental practice will represent and warrant that they will, at all times during the terms of this Agreement and thereafter, comply with all laws directly or indirectly applicable that may now or hereafter govern the gathering, use, transmission, processing, receipt, reporting, disclosure, maintenance, and storage of my information, and use their best efforts to cause all persons or entities under their direction or control to comply with such laws. I agree that the dental practice has the right to monitor, retrieve, store, upload and use my information in connection with the operation of such services, and is acting on my behalf in uploading my patient information. I understand the dental practice will use commercially reasonable efforts to maintain the confidentiality of all patient information that is uploaded to the web site on my behalf. I understand the dental practice CANNOT AND DOES NOT ASSUME ANY RESPONSIBILITY FOR MY USE OR MISUSE OF PATIENT INFORMATION OR OTHER INFORMATION TRANSMITTED, MONITORED, STORED, UPLOADED OR RECEIVED USING THE SITE OR THE SERVICES.
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NEW PATIENT FORMS Insurance And Financial Form

  •  Yes
  •  No

As a courtesy, our office will submit Insurance claims for you in most cases. If you do not have insurance, please respond "N/A".

  •  Self
  •  Spouse
  •  Child
  •  Other
  •  Yes
  •  No
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NEW PATIENT FORMS

SECONDARY DENTAL INSURANCE

  •  Self
  •  Spouse
  •  Child
  •  Other

NEW PATIENT FORMS Financial Agreement

Financial Responsibility, Assignment Of Insurance And Release

As a courtesy to the providers scheduled and the needs of other patients, I acknowledge that I will be charged $50 for a missed appointment or cancellation when providing less than 48 hours' notice. Additionally, I will be charged a $50 returned payment fee for any payment that is returned by my financial institution to Summit Family Dentistry as nonpayment. I have reviewed Summit Family Dentistry's financial policy. I acknowledge and agree to these terms and conditions.

I accept financial responsibility for all charges incurred during treatment whether or not they are covered by insurance. If I have insurance coverage as listed above, I assign Summit Family Dentistry any insurance benefits for services rendered. I authorize a release of all information necessary to secure payment and authorize the use of the below signature on all insurance forms. All accounts that become 30 days delinquent are subject to a 1.5% finance charge per month on the past due amount. This is an annual percentage rate of 18%.

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NEW PATIENT FORMS Medical History

Indicate which of the following you have had or have at present. By checking the box it will indicate a "Yes" response, leaving blank will indicate a "No" response.

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  •  By checking this box, I acknowledge that I have reviewed ALL questions/alerts on this questionnaire and responded accordingly. There are no other medical conditions or medications/allergies that have not been listed. I am aware that I must notify the practice of any future changes. I further consent to the performing of xrays and oral examinations
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NEW PATIENT FORMS HIPPA Release Form

MEDICAL INFORMATION RELEASE FORM

  •  Spouse
  •  Child(ren)
  •  Other
  •  Information should not be released to anyone.

This release information will remain in effect until terminated by me in writing.

Contact Information

I authorize Summit Family Dentistry to contact me at the phone numbers, emails, and any additional contact information provided by the office.

Acknowledgment of the Receipt Of Notice Of Privacy Practice

I acknowledge that I have been presented a copy of Summit Family Dentistry's Notice of Privacy Practices, which has an effective date of 09/22/2013 and which describes how my health information may be used and disclosed (Copies available in office and online). I understand that you have the right to change The Notice of Privacy Practices at any time, that I will be provided a copy of any updated version, and that I may contact you at any time to request a current Notice of Privacy Practices.

My signature below acknowledges the authorization of release of information, the authorization for leaving voicemail, and that I have been presented with a copy of the Notice of Privacy Practices. Note: You will electronically sign this form in our office.

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NEW PATIENT FORMS General Consent For Dental Procedures

GENERAL CONSENT FOR DENTAL PROCEDURES

You, the patient, have the right to accept dental treatment recommended by your dentist.  Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risk of the recommended procedure, alternative treatments, or the option of no treatment.   

Do not consent to treatment unless you discuss potential benefits, risks, and complications with your dentist, and all of your questions are answered.  By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.   

It is very important that you provide your dentist with accurate information before, during, and after treatment.  It is equally important that you follow your dentist’s advice and recommendations regarding medication, pre and post-treatment instruction, referrals to other dentists or specialists, and return for scheduled appointments.  If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.   

You are an important part of the treatment team.  In addition to complying with the instructions given to you by this doctor, it is important to report any problem or complications you experience so they can be addressed by your dentist.   

I, the patient, understand that I am entering into a contractual relationship with Summit Family Dentistry for professional care.  I further understand that meritless and frivolous claims for dental malpractice have an adverse effect upon the cost and availability of dental care and may result in irreparable harm to a dental office.  As additional consideration for professional care provided to me by this office, I agree not to advance directly or indirectly, any false, meritless and/or frivolous claim(s) of medical/dental malpractice against Summit Family Dentistry.    

Should a legitimate dental malpractice case or cause of action be initiated or pursued, I agree to use expert witness(es) who are members in good standing or and adhere to the guidelines and/ or code of conduct determined for expert witnesses by the American Dental Association and who practice primarily in the same specialty.  In further consideration for this, Summit Family Dentistry agrees to the same stipulations.   

I acknowledge a breach of the agreement may result in irreparable harm to Summit Family Dentistry’s reputation and business. Summit Family Dentistry and I agree in the event of a breach to allow specific performance and/or injunctive relief.   

As with all surgery, there are commonly known risks and potential complications associated with dental treatment.  No one can guarantee the success of the recommended treatment, or that you will not experience a complication or less than optimal result.  Even though many of these complications are rare, they can and do occur occasionally.   

Some of the more commonly known risks and complications of treatment include, but are not limited to the following: 

  • Pain, swelling, and discomfort after treatment.

  • Infection in need of medication, follow-up procedures, or other treatment.

  • Temporary, or on rare occasion, permanent numbness, pain, tingling or altered sensation of the lip, face, chin gums, and tongue along with possible loss of taste.

  • Damage to adjacent teeth, restorations, or gums.

  • Possible deterioration of your condition which may result in tooth loss.

  • The need for replacement of restorations, implants, or other appliances in the future.

  • Altered bite in need of adjustment.

  • Possible injury to the jaw joint and related structures requiring follow-up care and treatment, or consultation by a dental specialist.

  • A root tip, bone fragment, or a piece of a dental instrument may be left in your body and may need to be removed at a later time if symptoms develop.

  • Jaw fracture 

  • If upper teeth are treated there is a chance of sinus infection or opening between the mouth and sinus cavity resulting in infection or the need for further treatment.

  • Allergic reaction to anesthetic medication.

  • Need for follow-up treatment, including surgery.

This form is intended to provide you with an overview of potential risks and complications.  Do not sign this form or agree to treatment until you have read, understood, and accepted each paragraph stated above.  Please discuss the potential benefits, risks, and complications of recommended treatment with your dentist.  Be certain all of your concerns have been addressed to your satisfaction by your dentist before commencing treatment.   

 

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