English - Cash/Private Pay

Please correct the errors described below.

Health History Form

As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Includes area code
Includes area code

If you are completing this form for another person, what is your relationship to that person?

Do you have any of the following diseases or problems: (Encircle DK if you Don't Know the answer to the question)

If you answer yes to any of the 4 items above, please stop and return this form to the receptionist.

Dental Information

For the following questions, please select your responses to the following questions.

Medical Information

Please encircle your response to indicate if you have or have not had any of the following diseases or problems.

(Check DK if you Don't Know the answer to the question)

Joint Replacement

Women Only

Allergies

Are you allergic to or have you had a reaction to:
To all yes responses, specify type of reaction.

Congenital heart disease (CHD)

Except for the conditions listed above, antibiotic prophylaxis is no longer recommended for any other form of CHD.

NOTE: Both Doctor and patient are encouraged to discuss any and all relevant patient health issues prior to treatment.

I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful healthhistory and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forthabove have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do nottake because of errors or omissions that I may have made in the completion of 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.

FOR COMPLETION BY DENTIST

Office Guidelines

In order to provide excellent dental care, at comparable rates, this patient information serves as a communication tool to facilitate a mutual understanding between Oxford Dental Care and our patients in order to achieve and maintain the highest quality of oral health care. * Please initial next to each heading below. *

Your time is valuable to us and arriving on time for appointment reservations is paramount to achieving and maintaining excellent oral health care. We reserve time specifically for you and your dental care therefore, we request 48 business hours notice when changing an appointment reservation. Changes of appointment reservation may not be made via voicemail or email and must be made by talking with a team member of Oxford Dental Care. Any appointments that are not provided a 48 business hours notice will be charged a short notice changed appointment fee in the amount of $45.00.

Please have a picture ID available at your first appointment with Oxford Dental Care.

Imaging (intra and/or extra-oral) and examinations are key to quality of oral health diagnosis and treatment. If we do not have access to previous diagnosable images we reserve the right to charge a fee for these images. Treatment planning and case presentation: Our patient information and education includes; Consents, brochures and videos. Depending on your prescribed dental needs, an additional complimentary treatment conference may be necessary. When your treatment includes a referral to specialist, we will provide a referral slip and forward any necessary information to the referring doctor.

Payment for services is due at the time dental services are rendered and for your convenience, payments accepted are; cash, check, money order or credit card (Visa, MasterCard, Discover and Care Credit). A $20 fee will be applied to any account with a returned check or non -sufficient funds. Account balances remaining after 30 days from date of service, may be subject to collection by a third party. If your account is turned over to a collection agency, a 30% collection fee will apply to your account.

Our office will perform complimentary benefits verification for you and inform you prior to any estimated out-of-pocket expenses. I authorize the use of my signature below in order to submit any and all information required to process benefit claims or verification to the insurance company or companies I have provided by any form of transmission or communication. As long as your insurance carrier allows, we will accept assignment of benefits of your dental insurance. We will only file your primary insurance; filing of secondary policies will be your responsibility.

It is ultimately your responsibility to understand the parameters of your dental benefit policy. This is negotiated by your employer and insurance company. Common exclusions and limitations include, but are not limited to; late entrant and termination of policy. Additional questions regarding payment of your dental services by your insurance company may be directed and answered by contacting your insurance company or the human resources department of the policy holder's employer.

By signing below, I have read and understand the above information. I have had the opportunity to ask the team of Oxford Dental Care any questions that I may have regarding the above patient information and guidelines. I also understand that I am ultimately responsible for any debt incurred at Oxford Dental Care.

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.

Patient Acknowledgment Of Reciept Of Notice Of Privacy Practices And Consent/ Limited Authorization & Release Form

You may use to sign this acknowledgement & authorization. In refusing we may not be allowed to process your insurance claims

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original.

MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.

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.

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION:
(This includes step parents, grandparents and any care takers who can have access to this patient's records):

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In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize, that this office may recommend products or services to promote your improve health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

Office Use Only

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 information will be encrypted.

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