ESTD
2002

    PATIENT DETAILS

    Is patient minor :


    RESPONSIBLE PARTY / INSURANCE INFORMATION

    NOTE : If the Guardian & the Patient are the same person, You can leave this section blank.

    INSURANCE (IF APPLICABLE):


    RESPONSIBLE PARTY 2 / INSURANCE INFORMATION

    Is there a second guardian and / or additional insurance to add?

    OTHER INSURANCE (IF APPLICABLE):


    SLEEP / AIRWAY ISSUES


    DENTAL/MEDICAL HISTORY

    Please check if the patient has a history of the following medical conditions:



    Please check if the patient has, or ever had, any of the following habits?


    SIGNED CONSENT

    I understand the information given is correct and will be held in the strictest confidence. I also understand that it is my responsibility to inform this office of any changes in the patient’s medical status.

    I hereby authorize this office to perform an oral evaluation and consent to the taking of x-rays, photographs and other records (if necessary) to determine appropriate treatment on the above-named patient.

    I also authorize this office to leave messages about appointments on my voice mail or answering machine, and agree to receive e-mail reminders and text messages about appointments.

    HIPAA Patient Consent

    I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (a.k.a HIPAA or the Healthcare Privacy Act).

    I understand that by signing this consent, I authorize This Office to use and/ or disclose my protected healthcare information to carry out the following:

    • Treatment which includes direct and/ or indirect treatment by my other healthcare providers involved in my treatment.
    • Obtaining payment from third party payers, i.e. my dental and/or medical insurance company/companies.
    • The day to day healthcare operations of your dental practice.

    I have also been informed of, and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses of disclosures of my protected health information, and my rights under HIPAA.

    I understand that your reserve the right to change the terms of this notice from time to time and that I may request the most current copy of this notice.

    I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are not required to agree to use these requested restrictions.

    However, if you do not agree, you are bound to comply with this restriction. I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent will not be affected.

    By submitting this form you agree to the above mentioned consent statement