New Patient Forms

Sex:MaleFemale

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

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?YesNoDK

Do you have any disease, condition, or problem not listed above that you think I should know about?YesNoDK

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 understand 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 question, 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

FOR COMPLETION BY DENTIST

New Patient Screening History

Please state chief complaint
(Circle the appropriate response)

1. Do you have difficulty opening your mouth?YesNo

2. Do you hear noises from your jaw joints?YesNo

3. Does your jaw get "stuck", "locked", or "go out"?YesNo

4. Do you have pain in or around the ears or cheeks?YesNo

5. Do you have pain when chewing, yawning or opening wide?YesNo

6. Does your bite feel unusual or uncomfortable?YesNo

7. Have you ever had an injury to your jaw, head, or neck?YesNo

8. Have you ever had arthritis?YesNo

9. Have you previously been treated for a temporomandibular disorder?YesNo

If "YES" to #9 above, please provide the following:

Photography and Videography Consent

Clinical photography is an important facet of thorough treatment. In our practice, we use photography frequently to enhance the outcome of our clinical treatment.

Our comprehensive exam includes collecting appropriate history and data, taking radiographs, and making study casts. In addition to these important components of an initial exaln, diagnostic photography and"/or videography is often essential for proper evaluation and treatment. It documents pre-operative conditions and allows the doctor to study and treatment plan the case when the patient is not present. Photos and videography allow us to better evaluate, diagnose and treatment plan your dentistry.

Pre-operative photos and/or videos will be taken during the initial appointment(s). Other photos and/or videos will be taken during and after treatment. All photos and/or videos will be placed in your record as a digital file and will be available to you at any time. These files may be shared with any dentist or physician that you have seen or might be seeing in the future, in order to provide better communication and better treatment. These f,rles may be displayed on our website, on social media, on presentations to other healthcare providers for educational purposes, and/or to patients in the offrce who would benefit from
seeing the results achieved.

Your privacy is our commitment. Any displayed or shared images will be of your teeth, lips and some surrounding lip areas. In accordance with HIPAA laws, at no time arc any identiffing features shared with anyone aside from your treating doctors.

I acknowledge receipt of the photography notice and allow for photos to be taken, as described.

Financial Policy Form

Please allow us to welcome you to our practice and advise you of our financial policy. Existing patients are also required to complete this form in order to update our records for your file.

1. We require payment of your dental treatment be made at the time of each visit and/or as treatment progresses on continuing procedures regardless of your insurance coverage. Your insurance company will reimburse you. We are not responsible for any fees not covered by your insurance company, or for matching fees based on their "usual customary" reimbursement.

2. Since each individual's insurance coverage is different, we cannot provide details regarding coverage for your treatment or an exact estimate of amounts that will be reimbursed to you by your insurance company. Therefore, we suggest that you check with your insurance company about particulars regarding coverage as it relates to your treatment or ongoing care.

3. The statement you will receive at the time of treatment complies with the standards for insurance claim submissions. We utilize standard treatment codes required by insurance companies for claim submission. If you should choose to dispute your coverage with your insurance company, and your insurance company requests detailed documentation of your treatment in the form of written explanation, x-rays and/or photos we will be happy to provide that to you.

4. As a courtesy, and to save you time, we will assist you with submitting your insurance claim form(s) indicating that reimbursement be made directly to you provided your bill with us has been paid.
5. If it is necessary to cancel your appointment, we require a notice of at least 24 hours. You will be charged $50 for the appointment scheduled if it is cancelled or broken without 24-hour advance notice.
6. You will be responsible for paying a monthly finance charge of 1.5o/o ( 1 8% annually) on all amounts not paid within 90 days.

7. In the unlikely event that you should default payment for any amount due, we will place your account in the hands of a collection agency. You will then be charged an additional fee equal to the cost of collection.
I, understand and agree to the financial policy as stated above and acknowledge receipt of this financial policy.

I, have received a copy of this office's Notice of Privacy Practices.

For Office Use OnlyWe attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because:
lndividual refused to signCommunications barriers prohibited obtaining the acknowledgementAn emergency situation prevented us from obtaining acknowledgementOther (Please Specify)

Notice of Privacy PracticesTHIS NOTICE DESCRIBES HOW HEATTH INFORMATION ABOUT YOU MAY BE USED AND DISCTOSED AND HOW YOU
CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. OUR PROMISE TO YOU AND OUR LEGAL DUTY
We are required by applicable federal and State law to maintain the privacy Of your health information. We are also required to
give you the Notice about Our privacy practices, Our legal duties, and your rights concerning your health information. We must
follow the privacy practices that are described in this Notice While it is in effect. This Notice takes effect April 14, 2003, and Will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are
permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms Of Our
Notice effective for all health information that we maintain, including health information we created or received before we
made the changes. Before we make a significant change in Our privacy practices, we will change this Notice and make the new
Notice available upon request.
For more information about our privacy practices, or to request a copy Of our Notice, please contact us using the information
listed on this website.
USES AND DISCTOSURES OF HEATTH INFORMATION
The following examples describe different ways we may use or disclose your health information
Treatment. We may use your health information to provide you with dental treatment or services. We may disclose health information about you to dental specialists, physicians, or other health care professionals involved in your care.
Payment. We may use and disclose your health information to obtain payment from health plans and insurers for the care that we provide to you.
Health Care Operations. We may use and disclose health information about you in connection with health care operations necessary to run our practice, including review of our treatment and services, training, evaluating the performance of our staff and health care professionals, quality assurance, financial or billing audits, legal matters, and business planning and development.
Your Authorization. ln addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to dlsclose it to anyone for any purpose. lf you give us authorization, you may revoke it in writing at any tlme. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
To your Family and Friends. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare; but only if you agree that we may do so.
Persons lnvolved in Care: We may use or disclose health information to notify or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location,yourgeneral condition,ordeath. lfyouarepresent,thenpriortouseordisclosureofyourhealthinformation,wewill provide you with an opportunity to object to such uses or disclosures. ln the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgement disclosing only health information that is directly relevant to the person's involvement In your healthcare. We will also use our professional judgement and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
Marketing Health-Related Services. We will not use your health information for marketing communications without your written authorization.
Required by Law. We may use or disclose your health information when we are required to do so by law.
Victims of Abuse, Neglect or Domestic Violence. We may disclose health information to the appropriate government authority if we reasonably believe that you are a possible victim of abuse, neglect or domestic violence. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security. We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders. We may use or disclose your health information when contacting you to remind you of a dental appointment. We may contact you by using a postcard, letter, phone call, voice message, text or email.

PATIENT RlGHTS
Access. You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. You must make a request in writing to obtain access to your health information. We may charge you a reasonable cost-based fee for expenses such as copies and staff time. lf you request an alternative format, we will charge a cost-based fee for providing your health information in that format.
Disclosure Accounting. You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations, and certain other activities, but not before April 14, 2003. lf you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction. You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement, except in an emergency.
Alternative Communication. You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances.
Electronic Notice. lf you receive this Notice on our website or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AN D COM PTAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us at the address or phone number provided in the letterhead.
If you have any complaints about your privacy rights or how your health information has been used or disclosed, please contact us at the address or phone number provided in the letterhead.
You may submit a written complaint to the Secretary of the U.S. Department of Health and Human Services. We support your right to the privacy of your health information. We will not retaliate against you in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

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