New Patient Online Form

To get ready for your dental appointment, follow the steps below:

Step 1

Step 2

Step 3

Save paper! Complete and submit our new patient online form below.

Bring your dental insurance card/information.

Please let us know when you make your appointment if you have any special needs, such as handicap access, premedication with antibiotics, or allergies.

Patient Information

Name:

Your Date of Birth

Sex:

Male Female

Street Address

City

State

Zip Code

Best Contact Is?

Phone

Home Phone

Work Phone

Cell Phone

Married?

Yes No

How did you hear about our office?

Insurance Information

Insurance Company Name

Subscriber # or Social Security #

Number can be found on your insurance card.

Group #

Employer

If you have an insurance card, please provide photographs of the front of the card and the back of the card. Images must be uploaded in JPG, PNG, or PDF format.

Front of Card

Add file

Please upload a file

Back of Card

Add file

Please upload a file

If your spouse is the policy holder:

Spouse's Name:

Spouses Date of Birth:

Spouse's Social Security #:

Spouse's Employer:

FINANCIAL POLICY

I understand that I am financially responsible for all charges whether or not paid by my insurance company. I understand that estimates of benefits are estimates only. I also understand that any balance remaining after my insurance has paid is my responsibility to pay, and I accept my responsibility for full payment if my dental insurance claim exceeds 60 days. I understand that my insurance benefits are subject to my remaining benefits available, eligibility of the benefits for the services rendered, and coordination of the benefits. I authorize my insurance company to pay Amy S. Au DDS, Inc. all insurance benefits otherwise payable to me for the services rendered. I authorize the use of this signature on all insurance claim submissions. I authorize Amy S. Au. DDS, Inc. to release all necessary information to secure the payment of benefits. I have read the above conditions of treatment and payment and agree to their contents.

Patient, Parent, or Guardian Name:

Agree to Financial Policy

I have read and agree to the financial policy.

Date

APPOINTMENT CANCELLATION POLICY

When you schedule an appointment, we reserve that time and prepare in anticipation of serving you. If you should need to reschedule, we kindly request that you contact us by phone with advance notice of 2 business days. We understand that conflicts arise; however, not showing for your appointment or cancelling without adequate notice will result in a $50 charge and then discontinuation of services.

Patient, Parent, or Guardian Name:

Agree to Cancellation Policy

I have read and agree to the appointment policy.

Date

Medical History

Name of personal physician:

Street Address:

City:

State

Zip Code

Phone:

Approximate date of last visit:

Current health condition:

Excellent Good Fair Poor

Have you had any serious health problems within the last 5 years?

Yes No

Do you know your blood pressure?

Yes No

PLEASE LIST YOUR PRESCRIPTION MEDICATIONS:

PLEASE LIST ANY VITAMIN SUPPLEMENTS OR OVER-THE-COUNTER MEDICATIONS YOU ARE TAKING:

Have you had any serious illness not listed above?

Yes No

If yes, please list or describe your illness.

Dental History

Are you required to take antibiotics prior to dental treatment for any reason?

Yes No

Reason for today's visit:

Do you have any teeth that are bothering you?

Yes No

How do you feel about the appearance of your teeth?

Former dentist's name:

Date of last teeth cleaning?

Date of last Dental X-Rays?

Have you ever had any complications following dental treatment?

Yes No

Do you smoke or use tobacco products?

Yes No

Consent of Services

I consent to being a patient at Amy S. Au, DDS, Inc., and I have provided as accurate and complete a medical and personal history as possible including antibiotics, drugs, or other medications I am currently taking as well as those to which I am allergic. I will follow any and all treatment and post-treatment instructions as explained and directed to me and will permit the recommended diagnostic procedures, including X-rays.

During the course of treatment, I may undergo procedures in all phases of dentistry, including periodontics (gum treatment), oral surgery, fixed and removable prosthodontics (crowns, bridges and dentures), implant dentistry, restorative dentistry (such as fillings), oral pathology, cleanings, pediatric dentistry and radiography.

I understand that my treatment plan may change at any time, and that I am welcome to ask questions about any aspects of my dental treatment and will request information if I am confused. I am responsible for clarifying any aspects of my dental treatment that I am unsure about. No guarantees can be made of treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results.

I will pay in full any cost of treatment or insurance co-payments according to the office’s financial policy. I understand that even if an insurance pre-estimate is given or a procedure has been “preapproved,” I am responsible for any costs that my insurance does not cover.

Acknowledgement of Consent for Services

I acknowledge this Consent for Services

Your Name

Date

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW 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 HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 04/14/03, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

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 us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such cases using our professional judgment only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use you health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health of safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorize federal officials health information required for lawful intelligence, counterintelligences, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, letters or email.)

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

*You may refuse to sign this acknowledgement

I acknowledge this Notice of Privacy Practices

*Required Fields

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