Healthcare Dental Package

HEALTHCARE DENTAL PACKAGE

Patient Information

Patient Name:

Date of Birth:    Gender: Male Female Other

Emergency Contact

Insurance Information

Medical & Dental History

Current Medications:

Do you have any of the following? (check all that apply)

Heart disease / heart murmur
Diabetes
Bleeding disorder / anticoagulant therapy
Pregnant or attempting to become pregnant
Pacemaker / implantable device
Tobacco use

Dental Treatment Package Selection & Estimate

Select services to be provided as part of this dental package (check all that apply):

Routine prophylaxis (cleaning)
Radiographic exam (x-rays)
Comprehensive oral exam
Restorative fillings
Tooth extraction
Crowns / bridges
Tooth whitening / cosmetic services

Consent for Dental Treatment

I hereby authorize the dentist and staff to perform dental procedures as deemed necessary or advisable, including diagnostic procedures, local anesthesia, radiographs, and other treatments set forth above. I understand that all medical and dental care involves some degree of risk. Potential risks include, but are not limited to: infection, prolonged bleeding, swelling, tooth or root fracture, numbness or altered sensation, allergic reaction, failure of treatment, and the possibility of additional or alternative treatment(s) if findings during the procedure differ from expectations.

Alternatives to the proposed treatment and associated risks have been explained to me. I have had the opportunity to ask questions and understand that I may withdraw consent at any time prior to the procedure. The dentist will provide reasonable post-operative instructions; I agree to follow such instructions and understand that failure to do so may impair healing or treatment outcome.

Financial Policy & Assignment of Benefits

I accept financial responsibility for all charges not covered by insurance. I authorize release of information necessary to process insurance claims and assign benefits payable to the treating dental practice for services rendered. I understand that estimates are not a guarantee of payment by my insurer. I am responsible for deductibles, co-payments, and any charges denied by the insurer. Unpaid balances may be subject to collection actions and associated fees.

HIPAA Authorization and Release of Information

I acknowledge receipt of the practice's Notice of Privacy Practices describing how my protected health information may be used and disclosed. I authorize the release of my dental and medical records, including radiographs and clinical notes, to my insurer, referring providers, and other healthcare providers as necessary for treatment and payment. I understand I may revoke this authorization in writing at any time, except to the extent that action has already been taken in reliance upon it.

Release to family or designated persons for scheduling, test results, or billing matters: Yes No

Photography / Radiograph Consent

I consent to the taking of clinical photographs and radiographs as necessary for diagnosis and treatment. Such images may be used for treatment planning, consultation with other dental professionals, and education, without disclosure of personal identifiers unless additional authorization is provided.

Photographs/radiographs may be used for teaching or promotional purposes: Yes No

Acknowledgment

By signing below, I certify that the information provided in this Healthcare Dental Package is accurate to the best of my knowledge. I understand the risks, benefits, and alternatives of the proposed treatment and consent to the performance of such treatment by the dental practice and its agents. I accept financial responsibility as described above and authorize release of necessary information for claims and coordination of care.

Sign Now