Health History

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Thank you for choosing our practice for your dental needs. Please take a moment to enter or update your information to help us ensure the quality of your care is excellent.

Emergency Contacts:

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When you refer someone to Wooster Family Dental, would you prefer to receive a gift card or credit to your account? (Please select one)

Expectations

We respect our patients’ time. Therefore we do everything we can do to work efficiently on treatment. We request the same from you. Please be on time and give us a 48 hour notice if you need to adjust any appointment. All broken appointments will result in a $35.00 fee.

Dental Insurance Information

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    Health Information

    5. Symptoms or conditions below that you currently HAVE or HAVE HAD in the past year(s): (Please list the Year Diagnosed (DX))

    Consent for Services

    As a condition of treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from patients for the costs incurred in their care. Financial responsibility on the part of each patient must be determined before treatment.

    All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash/check/credit card at the time services are performed unless other arrangements are made.

    Patients with dental insurance understand that all dental services are charged directly to the patient and that he or she is personally responsible for payment of all dental services. This office will help prepare the patient’s insurance forms or assist in making collections from insurance companies and will credit any collections to the patient’s account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

    In consideration for the professional services rendered to me at this practice, I agree to pay the charges for the services at the time of treatment, or within ten (10) days of billing, I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. A $10.00 late payment fee may be added at our discretion to late accounts, unless previously written financial arrangements are satisfied.

    I have read the above conditions of treatment and payment and agree to their content.

    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.

    HIPAA Acknowledgement

    Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

    The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

    The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

    You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

    By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such revocation will not be retroactive.

    By signing this form, I understand that:

    • Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
    • The practice reserves the right to change the privacy policy as allowed by law.
    • The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
    • The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
    • The practice may condition receipt of treatment upon execution of this consent.

    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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