Healthcare Dental School Document

Dental School Patient Consent and Authorization

Clinic Identification

Dental School Clinic:

Patient Information

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

Emergency Contact

Insurance Information

Medical History

Please check all conditions that apply to your medical history:

Heart disease    High blood pressure    Diabetes    Bleeding disorder    Asthma / Respiratory disease    Kidney disease

Are you pregnant? Yes No   If yes, expected delivery date:

Do you use tobacco products? Yes No   If yes, type/frequency:

Dental History

Date of last dental visit:    Reason for visit:

Consent for Treatment and Educational Participation

I hereby authorize dental evaluation and treatment by dental students and authorized supervising faculty of the Dental School Clinic. I understand that students will perform examinations, radiographs, preventive, restorative, endodontic, periodontal, prosthodontic, oral surgery procedures, and administer local anesthetic; additional procedures may be performed as medically indicated and authorized below.

I understand the nature and purpose of proposed treatments, that no guarantee can be made as to outcome, and that risks include but are not limited to infection, bleeding, nerve injury, swelling, sensitivity, need for additional procedures, and allergic reaction to materials or medications. I have had the opportunity to ask questions and have received answers to my satisfaction.

Consent to receive treatment: I consent to dental treatment by students under supervision.

Consent to local anesthesia: I consent to local anesthesia administration if necessary.

Consent to sedation: I consent to minimal or moderate sedation under direct supervision if indicated (separate assessment and consent may be required).

Photography, Recording, and Teaching Use

For the purpose of diagnosis, treatment planning, and education, I consent to the taking of dental records including photographs, digital images, study casts, and videos. I understand such records may be used for teaching, case presentation, publication, and research in a de-identified manner unless I explicitly decline below.

I consent to photography/recording for clinical and educational use: Yes No

Authorization to Release and Third-Party Billing

I authorize the Dental School Clinic to release dental and medical information to my insurance carrier(s), referring dentists, and other healthcare providers as necessary to process claims and coordinate care. I authorize payment of insurance benefits to the Dental School Clinic for services rendered. I understand I am financially responsible for charges not covered by insurance.

Authorization to release records: I authorize release of information to insurer(s) and healthcare providers as described above.

Privacy and HIPAA Acknowledgment

I acknowledge that I have been offered access to the Dental School Clinic's Notice of Privacy Practices describing how my health information may be used and disclosed, and my rights regarding that information. I understand that the clinic will use my information for treatment, payment, and healthcare operations as described in the notice.

Acknowledgment of receipt: I acknowledge receipt of the Notice of Privacy Practices.

Financial Responsibility

I understand that I am responsible for payment of services rendered at the Dental School Clinic. I agree to provide accurate insurance information and to pay any co-payments, deductibles, or charges not covered by insurance. Failure to pay outstanding balances may result in collection action.

Financial responsibility acknowledged: I accept financial responsibility as stated above.

Patient Certification

I certify that the above information is true and accurate to the best of my knowledge. I have read and understand the consents and authorizations contained in this document. I understand I may withdraw consent in writing, except to the extent that action has already been taken based on this authorization.

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