Healthcare Dental Corporation Form

HEALTHCARE DENTAL CORPORATION FORM

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other/Prefer not to say

Emergency Contact

Insurance Information

Medical & Dental History

Current Medications (include dosage and frequency):

Allergies (medications, latex, metals, local anesthetic):

Please indicate if you have been diagnosed with any of the following (check all that apply):

Diabetes Heart disease Hypertension Asthma Bleeding disorder None of the above

Tobacco Use: Current Former Never

For female patients: Are you pregnant or suspect you may be pregnant? Yes No If yes, expected delivery date:

Consent for Dental Treatment

I, the undersigned, authorize Healthcare Dental Corporation and its designated practitioners and staff to perform diagnostic, therapeutic, and dental procedures as deemed necessary. I understand that all treatment carries risks that may include, but are not limited to, infection, bleeding, swelling, nerve injury, damage to adjacent teeth or restorations, need for additional or alternative treatment, failure of treatment, allergic reactions, and complications related to existing medical conditions.

I acknowledge that the nature, purpose, benefits, and commonly known risks of the proposed procedures have been explained to me in terms I understand. I have been given the opportunity to ask questions and they have been answered to my satisfaction. I understand I may withdraw consent at any time prior to the procedure.

I consent to the taking of radiographs (x-rays), intraoral and extraoral photographs, and digital records as necessary for diagnosis, treatment planning, patient records, and appropriate communication with other health care providers.

Anesthesia and Sedation: I understand local anesthesia and other agents may be used and that there are inherent risks associated with their use. I consent to administration of local anesthesia and, if indicated, nitrous oxide or moderate sedation as described by my treating clinician.

Financial Responsibility & Assignment of Benefits

I understand that I am financially responsible for all charges whether or not paid by my insurance. I authorize payment of dental benefits to Healthcare Dental Corporation for services rendered. I agree that a photocopy or electronic copy of this assignment is valid as the original.

I understand that estimates provided are not a guarantee of payment by my insurer and that I am responsible for any balance not paid by insurance, including deductibles, co-payments, and non-covered services.

HIPAA Authorization and Release of Information

I authorize Healthcare Dental Corporation to use and disclose my protected health information, including treatment records, diagnoses, dental images, and billing information for the purposes of treatment, payment, and health care operations. I understand that this authorization permits release of information to other health care providers, insurance carriers, and authorized persons involved in my care.

Purpose of Disclosure: Continuity of care, claims processing, and coordination with other providers. I understand that I may revoke this authorization at any time by submitting a written request, except to the extent that action has already been taken in reliance on this authorization.

Acknowledgements and Certifications

I certify that the above information is true and complete to the best of my knowledge. I understand that withholding information or providing inaccurate information may be harmful to my treatment and may place me at increased risk of complications.

I acknowledge receipt of the Notice of Privacy Practices and understand I may request a copy for my records. I consent to communicate appointment reminders, treatment information, and billing communications by phone, mail, and secure electronic means unless I have specified otherwise in writing.

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