Patient Intake Form

Welcome to Our Practice

Please fill out the information below before your first visit to our office. It is important to complete as much of this form as possible to expedite your visit and ensure that we have all the needed information.

1. About You

Patient's First Name

Middle Initial

Last Name

SSN

Email address

Birth Date

Gender:

Male Female

Address:

City:

State:

Zip:

Home Phone:

Cell Phone:

Employer:

Occupation:

Work Phone:

Referred By:

Spouse's Name:

2. Responsible Party

First Name:

Last Name:

Relation:

Address:

City:

State:

ZIP:

Email Address:

SSN:

Phone:

3a. Insurance Information - Primary Dental Insurance

Insurance Company:

ID #:

Group (Plan, Local or Policy #):

Subscriber (Employee):

Subscriber's Date of Birth

Insurance Phone:

Employer:

Work Phone:

3b. Insurance Information - Secondary Dental Insurance

Insurance Company:

ID #:

Group (Plan, Local or Policy #):

Subscriber (Employee):

Insurance Phone:

Employer:

Work Phone:

4. In Event of Emergency

Emergency Contact Name:

Relation:

Phone:

Secondary Phone:

Who is your Medical Doctor?

Medical Doctor's Phone:

5. Notice of Privacy Practices Acknowledgement

Notice of Privacy Practices

In the course of providing service to you, we create, receive, and store health information that identifies you. I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

Conduct, Plan, and Direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly
Obtain payment from third-party payers (e.g. my insurance company)
Conduct normal healthcare operations such as quality assessments and physician certifications

The Notice of Privacy Practices you have been given describes these uses and disclosures in detail. You are free to refer to this notice at any time before you sign this form. As described in our Notice of Privacy Practices, the use and disclosure of your health information for treatment purposes not only includes care and service provided here but also disclosures of your health information as may be necessary or appropriate for you to receive follow-up care from another health professional. Similarly, the use and disclosure of your health information for purposes of payment includes:

Our submission of your health information to a billing agent or vendor for processing claims or obtaining payment
Our submission of claims to third-party payers or insurers for claims review, determination of benefits and payment
Our submission of your health information to auditors hired by third-party payers and insurers

Other aspects of payment described in our Notice of Privacy Practices. Our Notice of Privacy Practices will be updated whenever our privacy practices change. You can receive an updated copy of this notice from our office.

You have the right to ask us to restrict the uses or disclosures made for purposes of treatment, payment, or healthcare operations, but as described in our Notice of Privacy Practices, we are not obliged to agree to these suggested restrictions. If we do agree, however, the restrictions are binding on us. Our Notice of Privacy Practices describes how to ask for a restriction.

I acknowledge that I have read, understand, and agree to the Notice of Privacy Practice above. I consent to the use and disclosure of my health information for purposes of treatment, payment, and healthcare operations.

6. Financial Policy Acknowledgement

Agreement to Pay For Treatment

The patient and/or responsible party listed below hereby agree to pay all charges submitted by Heritage Dental Studio L.L.C. TODAY, unless arrangements have been made with the front desk. If I do not pay the entire balance within 25 days of the monthly billing date, a late/ interest charge of 1.5% on the balance of the unpaid and owed will be assessed to my account each month. I realize failure to keep this account current may result in not being able to receive additional dental services, except for emergencies, unless there is prepayment on this account. I agree to pay collection costs and responsible attorney fees incurred in attempting to collect on this amount or any outstanding account balances.

A reminder, that you may receive 2 or more statements in one month due to the amount of times you visit the office in that month. Also, a 24-hour notice of cancellation is required to avoid a broken appointment charge. As a courtesy, our office will file charges to your insurance company. If for any reason your insurance company does not agree to pay for services you are responsible for that balance.

Consent to law, jurisdiction, and venue: “The terms of this agreement shall be governed by, construed, and enforced in accordance with the laws of the United States of America and the laws of the state of Indiana. The parties hereby agree that preferred jurisdiction and venue shall be strictly within the courts of Lake County, Indiana. The terms of this agreement have been accepted by the purchaser(s)/borrower(s)in the state of Indiana”.

I acknowledge that I have read, understand, and agree to the Financial Policy above.

7. Consent to Perform Dentistry

Consent to Perform Dentistry

I hereby authorize and direct the doctors of Heritage Dental Studio, to perform the following dental treatment or oral surgery procedure(s), including the use of any necessary or advisable local anesthesia, radiographs (x-rays), or diagnostic aids. This includes but is not limited to: Preventative hygiene treatment (prophylaxis), and the application of topical fluoride; Application of plastic "sealants" to the grooves of the teeth; Removal of decay and subsequent treatment (restoration, root canal, extraction, etc.); Treatment of diseased or injured teeth with dental restorations (fillings, composites, crowns); Replacement of missing teeth with dental prostheses (bridges, partial dentures, full dentures); Removal (extraction) of one or more teeth; Treatment of malposed (crooked) teeth and/ or oral development or growth abnormalities.
I understand that there are risks involved in this, or any, treatment and hereby acknowledge that these risks will be explained to me. I understand I will have an opportunity to ask questions regarding the treatment and the risks, and that I fully understand the same.
I will be advised that the success of the dental treatment to be provided will require that myself and/or responsible party follows post-operative instructions and post-care instructions of the dentist, and dental staff. I agree that the success of the treatment requires that all and post-care instructions be followed and that regular office visits as suggested by my dentist and his auxiliaries must be maintained.
I recognize that during the course of treatment unforeseen circumstances may necessitate additional or different procedures from those discussed. I therefore authorize and request the performance of any additional procedures that are deemed necessary or desirable to oral health and well being, in the professional judgment of the dentist.
There are possible risks and complications associated with the administration of local anesthesia, and drugs. The most common of these are swelling, bleeding, pain, nausea, vomiting, bruising, tingling, and numbness of the lips, gums, face, and tongue, allergic reactions, hematoma (swelling or bleeding at or near the injection site), fainting, lip or cheek biting resulting in ulceration and infection of the mucosa. I also understand that there are rare potential risks such as unfavorable reactions to medications in respiratory and cardiovascular systems. I understand and have been informed of the above risks and complications.
I also authorize the doctor to use photographs, radiographs, and other diagnostic materials and treatment records for the purpose of identifying, teaching, and researching scientific publications.
I hereby state that I have rad and understand this consent, and that all questions about the procedures will be answered in a satisfactory manner; and I understand that I have a to be provided answers to questions which may arise during and after the course of my treatment.
I further understand that this consent will remain in effect until such time that I choose to terminate it in writing and by an employee of Hertiage Dental Studio.

I acknowledge that I have read, understand, and agree to the Consent to Perform Dentistry above.

8. Authorization and Consent

By checking this box, I understand that the information I have given above is correct to the best of my knowledge, that it will be held in the strictest of confidence, and that it is my responsibility to inform the office of any changes to this information. I also authorize the dental staff to perform the necessary dental services I may need.

Name:

Today's Date:

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