Healthcare Dental Center Form

Healthcare Dental Center Form

Patient Information

Patient Name:

Male Female Other Prefer not to say

Emergency Contact

Insurance Information

Medical & Dental History

Please answer all questions honestly. Failure to disclose medical information may result in adverse outcomes.

Check any conditions that apply:

Heart disease Hypertension Diabetes Asthma

Bleeding disorder Pacemaker or implant Pregnant or trying to conceive Taking blood thinners

Tobacco use Other (specify below)

Consent for Treatment

I, the undersigned, authorize Healthcare Dental Center and its authorized providers to perform diagnostic procedures and dental treatment as deemed necessary. Treatment may include but is not limited to examinations, radiographs, prophylaxis, restorations, extractions, local/regional anesthesia, and emergency interventions. I understand that the practice of dentistry is not an exact science and that no guarantees can be made concerning the results of procedures.

I acknowledge that risks and complications may include infection, swelling, bleeding, pain, nerve injury, or reactions to medications or anesthesia. All known alternatives, risks, and benefits have been explained to me and I have had the opportunity to ask questions.

I understand that I may withdraw consent at any time prior to a procedure by notifying the treating clinician, except where revocation would jeopardize my safety during a procedure already in progress.

Consent to treatment: I give voluntary consent for treatment as described above.

HIPAA / Privacy Acknowledgment & Authorization

I acknowledge receipt of the practice's Notice of Privacy Practices and understand how my protected health information (PHI) may be used and disclosed for treatment, payment, and health care operations. I authorize the release of my dental records, including radiographs and treatment notes, to other health care providers, insurance carriers, and as required by law.

I authorize the practice to communicate appointment reminders, treatment information, and billing statements via phone, text message, and email at the contact information provided unless I have indicated otherwise in writing.

I consent to disclosure of my PHI to the following person(s) for appointment scheduling, payment, or treatment coordination:

Financial Responsibility & Assignment

I certify that I am financially responsible for all charges for services rendered to me or my dependent. I authorize payment of dental benefits to the treating provider when applicable and assign benefits to the provider. I understand that insurance is a contract between me and my insurer and that any unpaid balance is my responsibility.

I agree to pay collection costs, interest, and reasonable attorney fees for delinquent accounts if applicable. The practice may charge for returned checks and missed appointments in accordance with its policies.

Financial consent: I accept financial responsibility and assignment terms.

Acknowledgment & Certification

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I understand that withholding information or providing false information may have adverse health consequences and may affect the quality of care provided.

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