Patient Registration Form (English)

Parent / Guardian Information (only Complete if patient is under 18)

In Case Of Emergency

Cancellation / No Show Policy

Due to extreme demand for dental services, Community Dental Clinic appointments are booked several weeks in advance. When making an appointment, time and space are reserved especially for you. Instruments and supplies specific for your appointment needs, are sterilized and set-up in the treatment area. When you fail to keep your appointment, all these instruments must be re-sterilized and put away, thus resulting in wasted materials and money and increased waiting time to schedule future appointments. The time reserved for you cannot be used by anyone else without advance notice.

In order to better serve our patients, we ask for at least a 24-hour notice if you are unable to keep your appointment. Non-compliance or abuse of our cancellation policy will result in the dismissal of patients from our office. We confirm all our appointments prior to the date of appointment by calling the phone numbers listed above. Failure to confirm appointments by 12:00 pm of the prior business day will result in loss of appointments and possible dismissal of patients from our office.

Tardiness is not tolerated in this office! If you are late for your appointment, you may not be seen or rescheduled. Chronic tardiness will result in dismissal of patient!

Sign and date showing you have read and understand our Cancellation / No Show Policy

PLEASE NOTE: ANY PATIENT UNDER 18 YRS OF AGE MUST BE ACCOMPANIED BY LEGAL GUARDIAN OR AUTHORIZED ADULT (CONSENT FORM MUST BE ON FILE) DURING ENTIRE APPOINTMENT TIME.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Medical History

Common Blood Thinners Include: Aspirin, Plavix, Coumadin, or Warfarin

WOMEN

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

DENTAL TREATMENT CONSENT FORM

Please read and initial the items below and read and sign the bottom of form.

Photos

Any photos taken will be part of my dental record. I understand that they may be used for case presentations, clinic promotion, and continuing education within the Community Dental Clinic as well as outside providers to whom I may be referred. I understand that I will not be compensated for the use of these photos

Medications

I understand that antibiotics, analgesics, and other medications can cause allergic reactions causing redness and swelling of tissue, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction).

Changes in Treatment Plan

I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give my permission to the Dentist to make any/all changes and additions as necessary.

Nitrous Oxide

I understand that nitrous oxide (laughing gas) provides relaxation that may make it more comfortable for me to receive the necessary dental treatment needed with less anxiety. I will be awake, fully conscious, aware of my surroundings, and able to respond rationally. I have informed the doctor of my complete medical history including any recent surgeries or changes.

Local Anesthetic

I understand that there are risks of local anesthesia that may affect my body such as dizziness, nausea, vomiting, accelerated heart rate, slow heart rate, or various types of allergic reactions. It may also cause injury to nerves that can result in pain, numbness, tingling that may persist for several weeks, months, or rarely, be permanent. I have informed my doctor of my complete medical history including any recent surgeries or changes.

Restorations (Fillings)

I understand that care must be exercised in chewing on fillings especially during the first 24 hours to avoid breakage. I understand that a more expensive filling than is initially diagnosed may be required due to additional decay. I understand that significant sensitivity is a common after effect of a newly placed filling

Removal of Teeth

Alternatives to removal have been explained to me and I authorize the dentist to remove any teeth necessary for reasons explained to me. I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which are pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue, and surrounding tissue that can last for an indefinite period of time, or fractured jaw. I understand I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment, the cost of which is my responsibility.

Periodontal Loss (Tissue & Bone)

I understand that Periodontal Disease can be a serious condition, causing gum and bone inflammation and/or may lead to loss of permanent teeth. Possible treatment will be explained to me that may include deep tissue cleaning, gum surgery, extraction of teeth, and tooth replacement. I understand that much of the success of periodontal treatment depends on my continuing home care and strict observance of recall appointments. I understand that care by a specialist may be necessary.

I understand that dentistry is not an exact science and that, therefore, reputable practitioners cannot fully guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment which I have requested and authorized. I CERTIFY THAT I HAVE HAD AN OPPORTUNITY TO READ AND FULLY UNDERSTAND THE TERMS WITHIN THE ABOVE CONSENT AND EXPLANATION MADE AND THAT ALL STATEMENTS REQUIRING COMPLETION WERE FILLED IN BEFORE I SIGNED. I HAVE THE OPPORTUNITY TO HAVE ALL MY QUESTIONS ANSWERED BY MY DOCTOR AND I CERTIFY THAT I UNDERSTAND, SPEAK, READ, AND WRITE IN MY DESIGNATED LANGUAGE AND CAN PLAINLY SEE THESE WORDS WHICH I AM READING. MY SIGNATURE BELOW SIGNIFIES THAT I UNDERSTAND THE TREATMENT AND ANESTHESIA THAT IS PROPOSED FOR ME, TOGETHER WITH THE KNOWN RISKS AND COMPLICATIONS ASSOCIATED WITH THAT TREATMENT. I HEREBY GIVE CONSENT FOR THE TREATMENT I HAVE CHOSEN.

PLEASE ASK YOUR DOCTOR IF YOU HAVE ANY QUESTIONS ABOUT THIS CONSENT FORM.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Your Rights

The following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information

Under federal law, however, you may not inspect or copy the following records: Psychotherapy notes, information compiled in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information

You have the right to request a restriction of your protected health information

This means you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply.

Your physician is not required to agree to a restriction that you may request. If the physician believes it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional

You have the right to request to receive confidential communications from us by alternative means or at an alternative location. You have the right to obtain a paper copy of this notice from us upon request, even if you have agreed to accept this notice alternatively i.e. electronically.

You have the right to have your physician amend your protected health information.

If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, of your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice

Complaints

You may complain to us or the Secretary of Health and Human Services if you believe your privacy rights have been violated by us. You may file a complaint with us by notifying our privacy contact of your complaint. We will not retaliate against you for filing a complaint

This notice was published and becomes effective on/or before April 14, 2003

We are required by law to maintain the privacy of, and provide individuals with, this notice of our legal duties and privacy practices with respect to protected health information. If you have any objection to this form, please ask to speak with our HIPAA Compliance Officer in person or by phone at (270)691-6205.

Signature below is only acknowledgment that you have received this Notice of our Privacy Practices.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

Authorization For Release of Identifying Health Information

If you have Medicaid Insurance, you must complete this form in order for us to file a claim. Otherwise you will be responsible for all services rendered for treatment.

I authorize the professional office of my dentist named above to release health information identifying me under all circumstances pertaining to my dental care (including if applicable, information about HIV infection or AIDS, information about substance abuse treatment, and information about mental health services) under the following terms and conditions

1. Information will be provided to allow authorization and payment of services.
2. We may call or send reminders of appointments, we may disclose certain information to your pharmacy if medications are needed, and we may need to disclose personal and health information if necessary to refer for dental services not offered in our facility.
3. In all instances, Community Dental Clinic will show prudence and release only the minimum protected information necessary to a particular disclosure.
4. This authorization will expire if or when a written or electronic note is received.

It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization. Please be advised that if you refuse to sign this authorization, you will be financially responsible for any services provided since we will not be able to submit claims to your insurance provider. You also forfeit being able to receive any prescriptions from our office.

If you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us that your authorization is revoked. Send this note to the office address listed at the top of this form

When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes, state or federal law changes this possibility.

I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM.

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.

If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form

I give my permission for the following individuals to bring the above named patient to dental appointments at the Community Dental Clinic and to make any necessary medical/dental decisions for treatment. (Only complete if patient is under 18 years of age)

Must be 18 years of age or older & have a valid ID

I understand that individuals must present a valid ID when sigining in for the appointment.

I also understand that I must provide written notice if the individuals listed above are no longer allowed to escort the patient to the appointment

DISCLAIMER: By typing your name below, you are signing this application electronically. You agree that your electronic signature is the legal equivalent of your manual signature on this application.