Healthcare Dental Corporation

Healthcare Dental Corporation — Patient Intake, Consent & HIPAA Authorization

Patient Information

Patient Name:

Emergency Contact

Insurance Information

Medical History

Are you currently pregnant or breastfeeding? Yes No

Do you have a heart pacemaker or implanted cardiac device? Yes No

Consent for Treatment

I, the undersigned, authorize Healthcare Dental Corporation and its authorized clinicians, assistants and staff to perform diagnostic, dental and oral surgical procedures as recommended by the treating practitioner. I have been informed of the nature and purpose of the proposed treatment, the expected benefits and the material risks, including but not limited to infection, bleeding, nerve injury, tooth root fracture, tooth loss, need for additional procedures, and reactions to medications and anesthetic agents.

I understand that no guarantee has been made to me regarding the outcome or cure of the proposed treatment. I acknowledge that alternative treatments and reasonable alternatives have been explained to me and that I have had an opportunity to ask questions and receive answers to my satisfaction. I consent to the administration of local, topical or other indicated anesthesia and to the use of diagnostic tests and radiographs as necessary.

I understand that I may withdraw consent at any time prior to or during the procedure, and that withdrawal may necessitate postponement or termination of care. If I withdraw consent after the initiation of treatment, I accept responsibility for any additional care required as a consequence.

Financial Responsibility

I accept financial responsibility for services provided by Healthcare Dental Corporation. I authorize release of information necessary to process claims and understand that payment is ultimately my responsibility if insurance does not cover the charges in full. By signing below I consent to billing the insurance identified above and accept responsibility for co-payments, deductibles and non-covered services.

HIPAA Authorization & Privacy Acknowledgment

I acknowledge receipt of the privacy practices of Healthcare Dental Corporation describing the uses and disclosures of my protected health information. I authorize the practice to use and disclose my health information for treatment, payment and healthcare operations as necessary. I understand I may request restrictions on certain uses and disclosures and that such requests will be considered in accordance with law.

I specifically authorize Healthcare Dental Corporation to disclose my protected health information to the following persons:

By checking the box and signing below, I authorize Healthcare Dental Corporation to contact me by telephone, text message or email for appointment reminders, treatment information and billing communications at the numbers and addresses provided. I understand standard messaging charges may apply.

I consent to receive appointment and billing communications via phone, text and/or email.

Acknowledgments

I certify that the information I have provided on this form is true and complete to the best of my knowledge. I agree that a copy of this authorization may be treated as an original. I understand that this document constitutes informed consent for the dental care described above.

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