Healthcare Dental Care Agreement

HEALTHCARE DENTAL CARE AGREEMENT

This Dental Care Agreement ("Agreement") establishes the terms under which dental services will be provided by the Provider identified below and accepted by the Patient identified below. Provider shall include dentists, hygienists, dental assistants and other clinical staff as required to perform the agreed treatment. Patient acknowledges receipt of this Agreement, consents to the described treatment, and accepts financial responsibility as set forth herein.

Provider Information

Patient Information

Patient Name:

Date of Birth:    Gender:

Emergency Contact

Insurance Information

Medical & Dental History

Current Medications:

Allergies (medication, latex, metals, etc.):

Prior Surgeries / Hospitalizations:

Chronic Conditions (e.g., diabetes, heart disease):

Please indicate applicable conditions:

Pregnant or trying to become pregnant    Pacemaker or implanted device    Bleeding disorder / on blood thinners

Sensitivity / allergy to local anesthetic    Tobacco use    Other (see Medical Notes)

Proposed Treatment

Description of Proposed Procedure(s):

Consent for specific interventions (check all that apply):

Local anesthesia    Nitrous oxide (inhalation sedation)    Intravenous sedation / general anesthesia

Risks, Benefits and Alternatives

The benefits and expected outcomes of the proposed treatment have been explained to me. I understand that no procedure is without risk. Potential risks include, but are not limited to: infection, bleeding, prolonged healing, nerve injury (numbness or altered sensation), tooth or root fracture, need for additional procedures, allergic reactions to medications or materials, failure of the treatment to achieve intended results, and complications related to sedation or anesthesia. Alternative treatment options, including no treatment, have been presented and explained.

I acknowledge I have had an opportunity to ask questions about the nature, risks and benefits of the proposed treatment, and that my questions have been answered to my satisfaction. I understand that I may revoke consent at any time prior to the commencement of the procedure.

Radiographs / Imaging

I authorize the taking of diagnostic images and radiographs as necessary for diagnosis and treatment. I understand images are important diagnostic tools and that care will be taken to minimize exposure.

I consent to diagnostic radiographs and images as indicated.

Financial Agreement

Patient (or responsible party) agrees to be financially responsible for all charges not paid by insurance, including deductibles, co-payments, co-insurance, and services not covered by insurance. Provider will submit claims to insurance as a courtesy when insurance information is provided; however, ultimate responsibility for payment rests with the patient. Payment of co-payments and estimated patient portions is due at the time of service.

By signing below I authorize assignment of benefits to the Provider and direct my insurer to make payment directly to the Provider for dental benefits otherwise payable to me. I authorize release of any information necessary to process claims.

Cancellation policy: I acknowledge that cancellations or rescheduling less than 48 hours prior to a scheduled procedure may result in a cancellation fee. Returned check fee and collection costs, including reasonable attorney and collection fees, will be charged for delinquent accounts.

HIPAA Authorization & Privacy

I acknowledge receipt of the Provider's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I authorize the Provider to use and disclose my health information as necessary for treatment, payment, and healthcare operations. I understand I may request restrictions on certain uses and disclosures and that such requests will be considered but are not binding on the Provider.

I authorize the Provider to leave appointment reminders and brief clinical messages at the phone number(s) provided.

Release for Records / Additional Consent

I authorize the Provider to obtain prior dental and medical records and radiographs as necessary for my care and to release copies of records and radiographs to other treating health care providers as required for continuity of care.

I consent to release and obtain medical and dental records as described above.

Acknowledgment & Certification

I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I understand that withholding medical information may be dangerous to my health. I have read and understand this Agreement, and I consent to the treatment described above. I accept financial responsibility as stated herein and authorize assignment of benefits to the Provider when applicable.

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