Healthcare Medical and Dental Form

HEALTHCARE MEDICAL AND DENTAL FORM

Patient Information

Emergency Contact

Insurance Information

Medical & Dental History

Please list current medications, including prescription and over-the-counter medications, vitamins, and supplements. Include dosage and frequency.

Allergies (medication, latex, food, environmental). Include nature of reaction and severity.

Have you had any of the following conditions? Check all that apply.

Social history (check all that apply)

Consent for Medical and Dental Treatment

I hereby consent to the performance of routine diagnostic procedures and the rendering of medical and dental treatment as deemed necessary by the treating clinician and supporting staff. I understand that the practice will explain the nature of proposed procedures, reasonable alternatives, associated material risks, and expected benefits prior to treatment when feasible.

I acknowledge that no guarantee or warranty has been made as to the results of any examination or treatment. I have had the opportunity to ask questions and understand the information provided. I understand that I may withdraw consent at any time prior to or during treatment, except in emergencies where immediate treatment is necessary to prevent serious harm.

Risks, Benefits and Alternatives

The risks of treatment may include, but are not limited to, infection, bleeding, swelling, pain, damage to adjacent structures, allergic reaction to medications or materials, and the need for additional procedures. Benefits may include relief of symptoms, improved oral function, prevention of disease progression, and improved oral health. Reasonable alternatives, including no treatment, will be discussed when applicable.

Financial Responsibility & Assignment of Benefits

I accept financial responsibility for all charges for services provided to me by this practice. I authorize the assignment of benefits payable from my insurance carrier to this practice and authorize the release of medical information necessary to process claims. I understand that I am responsible for any portion not covered by insurance, including co-payments, deductibles, and non-covered services.

HIPAA Acknowledgment & Authorization to Release Information

I acknowledge that I have been offered or have received the facility's Notice of Privacy Practices describing how my protected health information may be used and disclosed and my rights under applicable privacy laws. I authorize the release of my health information, including dental records and radiographs, to the following individual(s) or organization(s) for continuity of care and billing purposes:

This authorization is valid until:

Certification of Accuracy

I certify that the information provided on this form is true and correct to the best of my knowledge. I will notify the practice promptly of any changes in my medical history, insurance coverage, or contact information. I understand that providing false information may adversely affect my care and financial responsibility.

Consent for Communications

I consent to receive appointment reminders, treatment information, and billing communications at the contact numbers and email provided above unless I indicate otherwise in writing.

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