Healthcare Family Dentistry Form

Healthcare Family Dentistry Form

Please complete this form to the best of your knowledge. The information provided will be used to plan and deliver dental care, process insurance claims when applicable, and comply with privacy and recordkeeping requirements. By signing this form you certify that the information is true and complete to the best of your knowledge and you consent to the evaluation and treatment described below.

Patient Information

Patient Name:    Date of Birth:

Male    Female    Other:

Responsible Party (if different from patient)

Emergency Contact

Insurance Information

Medical History

Are you taking any medications, including over-the-counter and supplements? If yes, list medications, dosage, and frequency.

Do you have any drug allergies or adverse reactions to medications?

Do you have, or have you had, any of the following conditions? (check all that apply)

Diabetes    Heart disease    Hypertension    Asthma    Bleeding disorders    Other:

Dental History

Date of last dental visit:

Do your gums bleed when brushing or flossing?   Yes    No

Do you grind or clench your teeth?   Yes    No

Do you use tobacco products?   Yes    No

Are you pregnant or trying to become pregnant?   Yes    No

Consent for Dental Treatment

I authorize Healthcare Family Dentistry and its authorized providers to perform diagnostic procedures, examinations, and dental treatment as may be necessary for proper dental care. I understand that treatment may include radiographs, scaling, fillings, extractions, administration of local anesthetics, and other procedures which will be explained as required. No guarantee or assurance has been made to me as to the results that may be obtained.

I acknowledge that I have had the opportunity to discuss the nature of the proposed treatments and potential risks, benefits, alternatives, and potential complications with the treating dentist. I understand that I have the right to refuse any proposed treatment and may withdraw consent at any time prior to or during treatment.

Privacy, Release and Assignment

I acknowledge receipt of the Practice's Notice of Privacy Practices and understand the Practice may use and disclose my protected health information for treatment, payment and health care operations. I authorize the release of any dental or medical information necessary to process insurance claims and to obtain payment. I assign and authorize payment of insurance benefits directly to the practice for services rendered to the extent permitted by my policy.

I permit the Practice to contact me by telephone or mail regarding appointments and account matters at the contact information provided.

Financial Acknowledgment

I understand that I am responsible for all fees associated with my dental care. I agree to pay for charges not covered by insurance, including co-payments, deductibles, and non-covered services. Should this account be referred for collection, I agree to pay collection costs and reasonable attorney fees to the extent permitted by law.

If insurance benefits are assigned to the Practice, I understand that the Practice will file the claim as a courtesy. I authorize release of any information required to process insurance claims and request payment be made directly to the Practice.

Acknowledgment and Certifications

By signing below I certify that the information provided on this form is accurate and complete. I understand that failure to disclose medical or dental history may result in complications or harm. I consent to the release and sharing of my health information as described above, and I understand this authorization is voluntary and may be revoked in writing except to the extent that action has already been taken in reliance on it.

If signing on behalf of the patient, I certify that I am the patient's legal guardian or authorized representative and have the legal authority to consent to dental treatment and to sign this form.

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