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Health History and 3 Consents

University Dental Care

112 W Foster Ave, Ste 201,
State College, PA 16801
8142348224

Patient Details( * mandatory to fill )

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

( * mandatory to fill )

If you are completing this form for another person, what is your relationship to that person?

Do you have any of the following diseases or problems?

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  •  DK
DENTAL INFORMATION( * mandatory to fill )
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MEDICAL INFORMATION( * mandatory to fill )
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Women Only 

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Allergies

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Please mark (X) your response to indicate if you have or have not had any  of the following diseases or problems. 

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Congenital heart disease (CHD) 

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 NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

 

I certify that I have read and understood the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have  been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form.

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HIPAA Consent Office Agreement And Consent to Perform Dentistry( * mandatory to fill )

HIPAA Consent

Our Notice of Privacy Practices provides information about how we may disclose protected health information about you. You have the right to review our notice before signing this consent. As provided in our notice, the terms of our notice may change. If we change our notice, you may obtain a revised copy by contacting the Compliance Officer.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment, or health care operations. We are not required to agree to this restriction, but if we do, we are bound to our agreement.

 

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment, health care operations, and outcomes research. You have the right to revoke this consent, in writing, except where we have already made disclosures in reliance on your prior consent.

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Office Agreement

Payment: We accept Cash, Check, Mastercard, Discover, American Express, Visa, and CareCredit Cards.


Insurance:
We will be happy to submit an insurance claim for you for services rendered in our office. It is your responsibility to inform us of any changes in your insurance carrier or policy. Our treatment is based on the dental need of the patient, not the insurance company benefits. We cannot render services to a patient on the assumption that the charges will be paid by the insurance company. As a courtesy we can contact your insurance company for a pre-determination of payment for major services, however the pre-determination amount provided by the insurance company is not a guarantee of payment. We will help in any way possible to file your claim or handle any insurance queries you may have. If you do not receive any correspondence from your insurance company within 60 days of your dental visit please contact our office to inform us of the situation.


Appointment Poilcy:
When appointments are scheduled that time is set aside specifically for you and your needs so that we may provide you with the best care. When a patient fails to come to a scheduled appointment or cancels without advanced notice we are unable to provide care to another patient in need. With this in mind we require 48 hours notice when cancelling or rescheduling an appointment. After two (2) broken appointments University Dental Care reserves the right to no longer schedule you as a patient in its office. We provide a reminder call as a courtesy, however, you are responsible for informing us of any changes to your phone number, address, or any other contact information. Since most appointments are scheduled weeks or months in advance we require a confirmation from you no more than seven (7) days and no less than two (2) days in advance of your appointment. If we are unable to get in contact with you or do not receive a confirmation according to the timeline above, University Dental Care reserves the right to remove any appointment up to 48 hours prior to the scheduled appointment time and it will be marked as a broken appointment. We will actively search to fill that vacant spot with another patient in need. If you call back and the original appointment time is still available we will put you back in the schedule and remove any penalty.


We are here to help. If you have any questions please feel free to ask us.


authorize the release of any information and/or x-rays relating to my dental treatment to the insurance company, attorney, or collection agency in collecting the costs of services provided. I authorize payment from my insurance company directly to my doctor. My signature on file applies to myself and to all dependents listed on my insurance plan.

 


I authorize the release of any information and/or x-rays to dental offices where I have been referred or to another office of my choosing.

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Consent to Perform Dentistry

I hereby authorize the Dentist(s) of University Dental Care, P.C. and/or dental auxiliaries of his/her choice, to perform any of the following dental treatments or oral surgery procedures including the use of necessary local anesthesia, radiographs, or other diagnostic aides.

  Preventative hygiene treatment (prophylaxis) and the application of topical fluoride 

  Application of sealants to the grooves of the occlusal surface of back teeth

  Treatment of disease or injured teeth with dental restorations (fillings and/or crowns)

  Replacement of missing teeth with dental prostheses (bridges, partial dentures, full dentures)

  Removal (extraction) of one or more teeth

  Treatment of diseased or injured oral tissues (hard or soft)

  Treatment of malposed (crooked) teeth and/or oral development or abnormal growths

  Suggest use of sedative drugs to control apprehension or disruptive behavior

I understand that there are risks involved in this treatment and hereby acknowledge that these risks will be explained to me and that I will have the opportunity to ask questions regarding the treatment and risks until I fully understand.

I agree to the use of local anesthesia.

I recognize that during the course of treatment, unforeseen circumstances may necessitate additional or different procedures from those discussed. I therefore authorize any additional procedures that are deemed necessary or desirable to my oral health and well-being in the professional judgment of the dentist.

There are possible risks and complications associated with the administration of local anesthesia and sedative drugs. The most common of these are: swelling, bleeding, pain, nausea, vomiting, bruising, tingling, and numbness of the lips; gums; face; and tongue and allergic reactions, hematoma (swelling or bleeding near the injection site), fainting, and lip and cheek biting resulting in the ulceration and infection of the mucosa. I also understand that there are rare potential risks, such as unfavorable reactions to medication such as respiratory and cardiovascular collapse (stopping of breathing) and lack of oxygen to the brain that could result in coma or death. I acknowledge that I have been informed of the above risks and complications.

I also authorize the doctors to use photographs, radiographs, or other diagnostic materials and treatment records for the purpose of teaching, research, and scientific publications.

I will be advised that the success of my dental treatment will be dependent on my compliance with post-operative and post-care instructions to be followed and by maintaining regular office visits as scheduled by my dentist and his/her auxiliaries.

I hereby state that I have read and understand the above and understand that all questions about the procedures will be answered in a satisfactory manner. I understand that I am responsible for providing answers to questions that may arise during or after the course of my treatment.

 

I further understand that this consent will remain effective until such time that I choose to terminate.

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If the patient is under the age of 18...

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