Healthcare Dental Practice Form

HEALTHCARE DENTAL PRACTICE FORM

Patient Information

Patient Name: 

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

Phone   Email   Text Message

Emergency Contact

Insurance Information

Medical History

Current medications (include dosage and frequency):

Allergies (medication, food, latex, dental materials):

Prior surgeries / hospitalizations (include dates and reason):

Chronic conditions (check all that apply):

Diabetes   Hypertension   Heart disease   Asthma   Bleeding disorder   Autoimmune disorder   Other

Are you pregnant or nursing?   Yes   No  Tobacco use:   Current   Former   Never

Dental History

Do you have pain, sensitivity or swelling?   Yes   No  Bleeding gums?   Yes   No

Consent for Treatment

Procedure(s) to be performed:

I understand that no dental procedure is without risk. Risks may include, but are not limited to, infection, bleeding, numbness, tooth fracture, need for additional procedures, or an adverse reaction to medications or materials. Benefits of the proposed treatment include improvement of oral function, elimination of pain, prevention of disease progression, and restoration of dentition. Alternative treatments, including non-treatment, have been explained to me where applicable.

By checking the box below I authorize and consent to the described dental treatment and any incidental or related procedures deemed necessary by the treating dentist. I have had the opportunity to ask questions and receive satisfactory answers.

I have read, understand, and consent to the proposed dental treatment.

Financial Responsibility

I accept responsibility for all charges for dental services provided to me or my dependent. I authorize the release of any information required to process claims and assign benefits to the dental practice where applicable. If my account becomes delinquent, I agree to pay reasonable collection costs, court costs, and attorney fees as permitted by law.

I authorize payment of dental benefits to the provider and accept financial responsibility as stated above.

Authorization for Release of Records & HIPAA Acknowledgment

I acknowledge receipt of the practice's Notice of Privacy Practices describing how my protected health information may be used and disclosed and how I can access this information. I understand that I may request restrictions on certain uses and disclosures, and that such requests will be considered by the practice but may be denied where permitted by law.

I authorize the release of my dental records, radiographs, and clinical information to other healthcare providers, insurance carriers, or third-party payers as necessary for treatment, payment, or health care operations. This authorization is valid until:

I understand that I may revoke this authorization in writing at any time except to the extent that action has already been taken in reliance on this authorization. I further understand that information disclosed pursuant to this authorization may be subject to redisclosure by the recipient and may no longer be protected by applicable privacy law.

Appointment Reminders and Communications

I consent to receive appointment reminders and communications related to my dental care via the contact methods I selected above. I understand that message and data rates may apply for electronic communications.

I consent to receive appointment reminders and practice communications.

Acknowledgments and Signature

By signing below I certify that the information I have provided on this form is true and accurate to the best of my knowledge. I have read and understand the consents, authorizations, and financial obligations contained herein. I acknowledge that I have had the opportunity to ask questions about my treatment and the contents of this form.

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