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NEW PATIENT FORMS

Summit Family Dentistry

12999 W. Bowles Drive,
Littleton, CO 80127
(303) 625-7997

Patient Information Form( * mandatory to fill )

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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Insurance And Financial Form( * mandatory to fill )
  •  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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( * mandatory to fill )

SECONDARY DENTAL INSURANCE

  •  Self
  •  Spouse
  •  Child
  •  Other
Financial Agreement( * mandatory to fill )

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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Medical History( * mandatory to fill )

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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HIPPA Release Form( * mandatory to fill )

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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