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Wellesley Dental Group

5 Seaward Rd,
Wellesley, MA 02481
(781) 237-9071

Patient Details( * mandatory to fill )
Contact Information( * mandatory to fill )
Primary Insurance details( * mandatory to fill )
Patient Health history( * mandatory to fill )
  •  Allergic to Acrylic
  •  Allergic to Codeine
  •  Allergic to Latex
  •  Allergic to Metal
  •  Allergic to Sulfa Drugs
  •  Allergic to Aspirin
  •  Allergic to Iodine
  •  Allergic to Local
  •  Anesthetics
  •  Allergic to Penicillin
  •  Anaphylaxis
  •  Radiation Treatments
  •  Other Allergy
  •  Cancer Chemotherapy
  •  Bio phosphonates (fosamax, Boniva, Actonel)
  •  Cortisone Medicine
  •  Blood thinners
  •  Diet Medications (phen phen, Redux)
  •  Taking oral contraceptives
  •  Please list all other medications.
  •  Osteoporosis
  •  Shingles
  •  Skin Cancer
  •  Skin Infections
  •  Artificial Joint
  •  Bruise Easily
  •  Cold Sores/Fever
  •  Blisters
  •  Hives or Rash
  •  Rheumatism
  •  Swelling of Limbs
  •  Tumors or Growths
  •  Asthma
  •  Crohn's Disease
  •  Digestive Diseases
  •  Heartburn
  •  Frequent Diarrhea
  •  Hepatitis A
  •  Hepatitis B or C
  •  Kidney Problems
  •  Liver Disease
  •  Parathyroid Disease
  •  Renal Dialysis
  •  Stomach/Intestinal Disease
  •  Thyroid Disease
  •  Ulcers
  •  Yellow Jaundice
  •  Anemia
  •  Angina
  •  Diabetes
  •  High Blood Pressure
  •  Hypoglycemia
  •  AIDS/HIVPositive
  •  Arthritis/Gout
  •  Artificial Heart Valve
  •  Blood Disease
  •  Blood Transfusion
  •  Breathing Problem
  •  Chest Pains
  •  Congenital Heart
  •  Disorder
  •  Easily Winded
  •  Emphysema
  •  Excessive Bleeding
  •  Frequent Cough
  •  Heart Attack/Failure
  •  Heart Murmur
  •  Heart Pace Maker
  •  Heart Trouble/ Disease
  •  Hemophilia
  •  High Cholesterol
  •  Irregular Heartbeat
  •  Leukemia
  •  Low Blood Pressure
  •  Lung Disease
  •  Mitral Valve
  •  Prolapse
  •  Sickle Cell Disease
  •  Stroke
  •  Alzheimer`s Disease
  •  Epilepsy or Seizures
  •  Frequent Headaches
  •  Psychiatric Care
  •  Spina Bifida
  •  Facial Injuries and Disorders
  •  Gum Disease
  •  Grinding Teeth
  •  Tooth Sensitivity
  •  TMJ
  •  Jaw Pain
  •  Dry Mouth
  •  Pain in Jaw Joints
  •  Cancer
  •  Cold Sores
  •  Drug Abuse
  •  Glaucoma
  •  HPV
  •  Sleep Apnea
  •  Sleep Disorders
  •  Snoring
  •  Tuberculosis
  •  Chemotherapy
  •  Convulsions
  •  Drug Addiction
  •  EDS + mast cell activation. have epi pen
  •  Excessive Thirst
  •  Fainting Spells/ Dizziness
  •  Genital Herpes
  •  Hay Fever
  •  Herpes
  •  Migraine Headaches
  •  No Listerine
  •  Nursing
  •  Pregnant/Trying to get pregnant
  •  Recent Weight Loss
  •  Rheumatic Fever
  •  Scarlet Fever
  •  Sinus Trouble
  •  Tonsillitis
  •  Venereal Disease

I certify that the  information I have provided is true.

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HEALTH HISTORY UPDATE( * mandatory to fill )
  •  Yes
  •  No
  •  Yes
  •  No
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Patient Financial Agreement( * mandatory to fill )

This agreement is to inform you of your financial obligation to our practice. We are committed to providing you with the most comprehensive dental care using the highest quality materials and technology available in the market today.

We are also committed to providing you with up-to-date information and educational tools so that you may fully participate in maintaining optimum oral health. This financial agreement is intended to facilitate our ability to provide excellent service to you while minimizing our administrative costs.

All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your
insurance policy is an agreement between you, your employer, and the insurance company. Our practice is not a party to that agreement. If payment from your insurance company is not received within 60 days from date of
service, you will be expected to pay the balance in full.

As a courtesy to you, we will help you process all your insurance claims. You may direct your insurance company to pay your benefits directly to our practice by signing the authorization on the Assignment of Benefits Agreement. In order for our practice to file your insurance claim, you must provide us with accurate, updated information.

Your estimated co-payment for treatment, which is the amount not covered by your insurance, is due at the time treatment is provided. Your estimated co-payment may be adjusted after the time of treatment depending upon the final reconciliation of insurance payments. If you are uninsured, full payment for all services is due on the date of service.

Our practice accepts cash, personal checks, MasterCard, Visa, American Express, and Discover. Third party, extended payment financing is available upon request and approval. Returned checks and balances older than 60 days will be subject to collection fees and finance charges.

I hereby authorize payment directly to Wellesley Dental Group for services rendered otherwise payable to me. I authorize release of information required to complete insurance claims.

I have signed to acknowledge that I understand this statement and I have accepted responsibility for all fees incurred for my dental care. I understand that future appointments may be contingent upon my having met my
financial obligations with the office, or having made appropriate arrangements with Wellesley Dental Group in advance.

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Notice of Privacy Practices( * mandatory to fill )


Wellesley Dental Group

Wellesley Dental Group is required by law to maintain the privacy of your protected health information (PHI) and to provide individuals with notice of its legal duties and privacy practices currently in effect with respect to PHI. This Notice describes how we may use and disclose your PHI for treatment, payment, and for health care operations as well as for other purposes that are permitted or required by law. 45 CFR § 164.520.

Wellesley Dental Group reserves the right to change the terms of this Notice and make the new notice provisions effective for all the PHI we maintain. If Practice makes a material change to this Notice, we will post the changes promptly on our website at A paper copy of this Notice is available upon request.

Effective Date

This Notice of Privacy Practices became effective on April 14, 2003, and was amended on 12/27/2011.

Types of Uses and Disclosures of your PHI

Treatment” – We will use and disclose your PHI to provide, coordinate or manage your dental health care and any related services. We will also disclose PHI to other providers who may be treating you such as a specialist.

Payment” – We will use your PHI to obtain payment for the dental health care services provided. For example, we may provide information to a health insurance company or business associate to obtain payment for the treatment provided for you.

Healthcare Operations” –We will use your PHI to support the management of our dental office. For example, we may use information about you to conduct quality performance reviews regarding our services or the performance of our staff. Additionally, we may obtain services from business associates such as training programs, legal services, and insurance.

HITECH Amendments

HITECH Act Breach Notification Requirements: The HITECH Act requires us to notify each individual whose unsecured PHI has been, or is reasonably believed to have been accessed, acquired or disclosed due to a breach. The HITECH Act imposes a similar requirement on Business Associates. “Unsecured PHI” refers to PHI that is not secured through the use of technologies or methodologies that render the PHI unusable, unreadable, or indecipherable to unauthorized individuals.

Restriction of Disclosure: The HITECH Acts restricts us from refusing an individual’s request not to use or disclose the individual’s PHI in instances where the patient’s services were paid out of pocket to prevent the information from flowing to the health plan since no claim is being made against the third party payer.

Access to Electronic Health Records (EHRs): The HITECH Act expands the right of records access. Individuals have the right to access their EHR in an electronic format and to direct us to send the e-record directly to a third party. We may only charge for the labor costs to transfer this information.

Expansion of Accounting of Disclosures: The HITECH Act removed the accounting of disclosures exception of PHI to carry out treatment, payment and healthcare operations. All such disclosures must be accounted for if the disclosure is made through an EHR. We also will provide the individual with a list and contact information for all relevant business associates to obtain an accounting of disclosures of PHI.

Prohibition on Sale of PHI: The HITECH Act prohibits covered entities and business associates from receiving indirect or direct remuneration in exchange for PHI without obtaining an authorization from the individual unless such an exchange meets one of the exceptions listed by the government.

Wellesley Dental Group’s Responsibilities

Certain Uses or Disclosures: We will use and disclose your PHI when required to by federal, state or local law.

Appointment Reminders: We may contact you to provide appointment reminders via telephone or postcards. We may contact you to provide information about treatment alternatives or other health-related benefits and services that may be of interest to you.

Revocation: Other uses and disclosures will be made only with you are written authorization and you may revoke such authorization.

Public Health & Safety: We will use and disclose your PHI to public health authorities permitted to collect or receive information for the purpose of controlling disease, injury or disability.

Individual Rights

Request Restriction of Disclosures: You have the right to request restrictions on certain uses and disclosures of PHI and under HIPAA, Wellesley Dental Group is not required to agree to the restriction unless as clarified by defined by the HITECH Act.

Right to Receive Confidential Communications: You have the right to receive confidential communications. Please specify your preference of communication in writing to us such as your home telephone, work telephone, mobile telephone, and/or email. We may provide relevant portions of your PHI to a family member, relative, close friend or any other person you identify as being involved in your dental care or payment.

Right to PHI: You have the right to inspect and copy the PHI that we maintain about you in our designated record set for as long as we maintain the information. We may charge a fee for the costs of copying, mailing or other supplies sued in fulfilling your request. Please contact the Privacy Officer to inspect your record or receive a copy.

Right to Amend: You have the right to request that we amend your health information if you feel it is incomplete or inaccurate. You must make the request in writing to our Privacy Officer stating the reasoning that supports your request. We may deny the request if the information was not created by our office or if the person who created it is no longer available to make this amendment.

Right to Accounting: You have the right to receive an accounting of disclosures of your health information as required by law. Please submit a written request to our Privacy Officer.

Right to Paper Copy: You have a right to obtain a paper copy of the Notice of Privacy Practices.

Request Information or File a Complaint

If you have questions, would like additional information or want to report a problem regarding the handling of your PHI, you may contact the Privacy Officer at:

Wellesley Dental Group
5 Seaward Road
Wellesley, MA 02481
Phone: 781-237-9071

Additionally, if you believe your privacy rights have been violated, you may file a written complaint at our Practice. You may also file a complaint with the Secretary of Health and Human Services at:

U.S. Department of Health & Human Services

Office of Civil Rights
200 Independence Avenue, SW
Room 515 F HHH Building
Washington, D.C. 20201

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Acknowledgement of Receipt of Notice of Privacy Policies( * mandatory to fill )

I have received a copy of the Notice of Privacy Practices of Wellesley Dental Group. I hereby authorize, as indicated by my signature below, to use and to disclose my protected health information for any necessary clinical, financial, and insurance purpose.

  •  You may contact me at my home telephone number
  •  You may contact me on my mobile telephone number
  •  You may contact me on my work telephone number
  •  You may email me

Please list authorized persons with whom we may discuss your Protected Health Information (PHI) in addition to custodial parents and legal guardians:

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Patient Appointment Agreement( * mandatory to fill )

We make every effort to value your time and schedule your appointment time just for you.

We truly appreciate your courtesy of giving us 2 business days' notice (by phone) if you have a conflict with your appointment and need to schedule a different day or time. We are committed to your oral health and keeping your scheduled appointments allows us to be partners in your dental care.

I acknowledge my appointment is a reservation.

I acknowledge I am required to provide 2 business days' notice to make any changes to my appointment. As a standard practice, if less than the required time is provided, a missed appointment fee of $75 per hour scheduled will be applied to your account.

I acknowledge 8:00 am and 4:00 pm appointments are considered VIP appointments, and if I miss an appointment without providing 2 business days' notice, I may not be able to schedule another VIP appointment.

I acknowledge after 2 appointments in which I do not provide appropriate notice, I may be required to leave a deposit in order to schedule my next appointment.

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