Patient Information Patient Info FormPersonal InformationNameDOBAddressCityStateZipHome PhoneCell PhoneWork PhoneEmail May we text you? Yes No Patient Name Sex DOB MaleFemale PreviousNextConfidential and Emergency Contact Information.Please list the family members (or other persons), if any, with whom we may discuss dental treatment and/or diagnosis and release records.NamePhoneConsent Emergency contact Discuss treatment Consent for treatment Release RecordsNamePhoneConsent Emergency contact Discuss treatment Consent for treatment Release RecordsNamePhoneConsent Emergency contact Discuss treatment Consent for treatment Release Records I authorize the office employees to send school excuses to the school employees and to inform the school if my child had a dental appointment and the date release to go back to school.PreviousNextPatient Pharmacy InformationPharmacy NamePharmacy AddressPharmacy Phone NumberDental InformationAre you having any pain or sensitivity at this time (or recently)? Yes NoIf yes, please explainDo you have any dental problems right now that you are aware of? Yes NoIf yes, please explainPreviousNextInsurance Filling AuthorizationI have been informed of the treatment plan and associated fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law, or the treating dentist or the dental practice contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to the use and disclosure of my protected health information to carry out payment activities in connection with all claims associated with the recipients on my insurance plan. I hereby authorize and direct payment of the dental benefits otherwise payable to me, directly to the above dental entity.PreviousNextConfidential Communication RequestAs required by the Health Information Portability and Accountability Act of 1996 (HIPAA) you have a right to request that communications concerning your personal health information be made through confidential channels. We will not ask you why you are making your request and will try to accommodate all reasonable requests.Hereby requests the use of the following confidential channels for the communication of information related to my personal health, treatment or payment for treatment. This request supersedes any prior request for confidential channel communications I may have made.Please select all that apply.PhoneI want you to contact me by telephone at this primary numberLeave messages on my answering machine or voicemail. Yes NoLeave messages with any other person. Yes NoMailI want you to contact me at this email addressFAXI want you to contact me at this fax numberOTHER REQUESTS FOR CONFIDENTIAL COMMUNICATIONS (SPECIFY) I agree and confirmNameConsent by Guardian Relationship *Address * By checking this box, I acknowledge that I have read, understood, and agree to the terms and conditions. Previous Submit Form
