Patient Registration Form

Primary Dental Insurance

Additional Dental Insurance

Dental History

Authorization

All insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

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 Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

Women: Are you...

Office Consent and Policy

OFFICE CANCELLATION OFFICE

We require a 24HR notice for cancellation of appointments. There will be a $50 charge for missed appointment or cancellations less 24HRS in advance. This charge is not covered by insurance.

OFFICE PRIVACY POLICY

I acknowledge that I have redivide a copy of this office's Privacy Policy Notice & have answered all questions on these forms a accurately & to the best of my knowledge.

OFFICE FINANCIAL POLICY

All dental services performed must be paid for at the time the services are rendered, if the patient does not have dental insurance. Patients, who carry dental insurance, understand that dental procedures will be billed to the insurance company at the time they are performed, as a courtesy from our office. If you have insurance, it is basis &/or major services? Insurance benefits & treatment plans are only an estimate & are subject to change. This dental office cannot render services on the assumption that our charges will be paid in full by an insurance company. A finance charge of 1.5% per month will be imposed on all goods & services not paid for within 90 days. This an annual percentage of 18%. If collection is made by suit or otherwise, patient &/or responsible party agrees to pay interest until paid, collection costs of 33.3% of the remaining balance & all attorney fees & court costs. I grant permission to you or your assignee to phone me at home, on a mobile device or my workplace to discuss matters related to this form.

CONSENT TO PROCEED

I authorize Dr. Moore &/or such associates or assistant as he may designate, to perform those procedures as may be deemed necessary or advisable to maintain my dental health of any minor or other individuals for which I advisable to maintain my dental health or the dental health of any minor or other individuals for which I have a responsibility, including arrangement &/or administration of any sedative (Nitrous Oxide), analgesic, therapeutic &/or pharmaceutical agent(s), including those related to restorative, palliative, therapeutic or surgical treatment, I understand that administration of local anesthetic may cause an untoward reaction or side effects which may include, but are not limited to a bruising, hematoma, cardiac stimulation, muscle soreness & temporary or rarely permanent numbness. I understand that occasionally needles break & may require surgical retrieval. Occasionally drops of local anesthetic may contact the eyes & may require irritation. I understand that as part of the dental treatment, including preventative procedures such as cleanings & basic dentistry, including fillings of all types. Teeth may remain sensitive or even possibly quite painful during & after completion of treatment, Dental materials & medications may trigger an allergic &/or sensitive reaction.

After lengthy appointments, jaw muscles also be sore or tender. Holding one's mouth open, in a predisposed patient, can precipitate a TMJ disorder. Gums & surrounding tissues may also be sensitive &/or painful during &/or after treatment. Although rare, it is also possible for the tongue, cheek, or other oral tissues to be inadvertently abraded or lacerated (cut) during routine dental procedures. In some cases, sutures or additional treatment may be required.

I understand that as part of dental treatment items including, but not limited to, crowns, small dental instruments, drill components, etc. may be aspired (inhaled into the respiratory system) or swallowed. This unusual situation may require a series of x-ray to be taken by a physician or hospital & may, in rare cases, require bronchoscopy or other procedures to ensure safe removal.

I understand the need to disclose to the dentist any prescription drugs that are currently being taken or that have been taken in the past, such as Phen-Fen. I understand that taking the class of drugs prescribed for the prevention of osteoporosis, such as Fosamax, Boniva, or Actonel, may result in complications of non-heading of the jawbones following oral surgery or tooth extractions. I do voluntarily assume any and & all possible risks, including the risk if substantial & serious harm, if any, which may be associated with general preventive & achieved, for my benefit of my minor child. I acknowledge that the nature & purpose of the foregoing procedures have been explained to me if necessary & I have been given the opportunity to ask questions.

Office Information

Nitrous is available upon request. It is at an additional $69 which is NOT covered by most insurances, We also offer sedatives by Rx only, but they require someone to drive you to & from your dental appointments. Netflix in the operatories for your enjoyment.

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.

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW DENTAL HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR DENTAL HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY

We are required by law to maintain the privacy of your dental health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your dental health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect June 22, 2009, and will remain in effect until we replace it.

We may change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We may make the changes in our privacy practices and the new terms of our Notice effective for all dental health Information that we maintain, including dental health information we created or received before we made the changes. The effective date of the Notice is provided above.

You may request a copy of our Notice at any time. For more Information about our privacy practices, or for additional copies of this Notice, please contact the Privacy Officer whose contact information Is provided at the end of this Notice.

USES AND DISCLOSURES OF DENTAL HEALTH

We may use and disclose dental health Information about you for treatment, payment, and healthcare operations. For example:

Treatment - We may use or disclose your dental health information to another dentist or healthcare provider providing treatment to you, or if we refer you to another health care provider.

Payment - We may use and disclose your dental health information to obtain payment for the services we provide to you. We may need to share part of your dental health information with our billing department, your insurance company, collection agencies or attorneys assisting us with collections, and others who are responsible for your bills, such as your spouse, as necessary for us to collect payment. For example, we may give information about a dental procedure that you had to your dental insurance company so it will pay us or reimburse you for your dental procedure.

To your Family Friend. and Other Personal Involved In Your Care: We may share with a family member, friend or other person identified by you, your dental health information that is directly related to that person's involvement in your care or payment for your care, or to notify such individuals of your location or general condition, but only if you agree that we may do so, or, based on our professional judgment, we determine that you would not object to the disclosure. We will also use our professional judgment and our experience in allowing a person to pick up supplies, X-rays, or other similar forms of health information on your behalf.

Use and Disclosure Of Health Information Required by Law: We may use and disclose your dental health information when required by federal or state law; when required In court or administrative proceedings; for public health activities; to dental health oversight agencies; to coroners, medical examiners, and funeral directors; to the military; to federal officials for lawful intelligence and national security activities; to correctional institutions regarding inmates; to law enforcement officials; to report abuse, neglect, or domestic violence; to avert a serious threat to your health or safety or the health and safety of others; and as authorized by state worker's compensation laws.

Contacting You: We may use and disclose your dental health information to contact you about appointments and other matters. We may contact you by telephone, email, or mail. We may leave your messages at the Telephone number you give us.

PATIENT RIGHTS

Right to See and Copy Your Health Information: You have the right to see or get copies of your dental health information, with limited exceptions. If we deny your request due to one of these exceptions, we will respond to you in writing with the reason we cannot grant your request, and describe any rights you may have to request a review of our denial. You must make a written request to us to access your health information. Your written request must be signed and dated. We may charge you a fee for expenses such as copies, staff time, and postage. Instead of providing you with a copy of your dental health information, we may prepare a summary Or an explanation of your health information for a fee, If you agree In advance to the form and fee of the summary or explanation.

Right to Request Alternative Communication: You have the right to request that we communicate with you about your dental health information by alternative means or at alternative locations. For example, you can ask that we only contact you at work, or only by mail. You must make your request in writing and your request must be signed and dated. Your request must specify the ways In which you wish to be contacted. You do not need to tell us the reason for your request.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, you may complain to us using the contact Information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services.

We support your right to the privacy of your health information. We will not retaliate in any way If you choose to file a complaint with us or with the U.S. Department 01 Health and Human Services.

PRIVACY OFFICER

Should you wish to contact the Privacy Officer, you may do so at the address and telephone number below.

Privacy Officer
Dr Peter S. Moore, D.D.S.
7555 S. Center View Crt, #103
West Jordan, Utah 84084
801-748-4151 801-748-0307 (fax)

Acknowledgment of Receipt of HIPAA Notice of Privacy Practices

You May Refuse to Sign This Acknowledgement

I, ____________, have received a copy of this office's Notice of Privacy Practices.

For Office Use Only