New Patient Forms

Patient Information

Date

Last Name

First Name

Address

City

State

Zip

E-mail

Sex

M F

Age

Birthdate

Marital Status

Married Widowed Single Minor Separated Divorced

SS#

Patient Employer/School

Occupation

Employer/School Address

Employer/School Phone

Spouse's Name

Birthdate

SS#

Spouse's Employer

Whom may we thank for the referral?

Phone Numbers

Home

Work

Ext

Cell Phone

Best time to reach you?

In Case of Emergency, Contact

Name

Relation

Home

Work

Cell

Dental Insurance

Subscriber's Name

SS#

Birthdate

Relationship to Patient

Insurance Co.

Group #

ID #

Is patient covered by additional insurance?

Yes No

Subscriber's Name

SS#

Birthdate

Relationship to Patient

Insurance Co.

Group #

ID #

Assignment and Release

I certify that I, and/or my dependent(s), have insurance coverage with

and assign directly to Dr. Dehelean all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charge whether or not paid by the 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.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature of Patient, Parent, or Guardian

Date

Name of Patient, Parent, or Guardian

Relationship to Patient

Dental History

Reason for Today's Visit

Former Dentist

Last Dental Visit

Last x-rays

How often do you floss?

How often do you brush?

Health History

Please select Yes or No to indicate if you've had the following:

No Medical Conditions

Yes

Abnormal Bleeding

Yes No

Acid Reflux

Yes No

ADHD/ADD

Yes No

AIDS/HIV

Yes No

Alzheimer's

Yes No

Anemia

Yes No

Angina/Chest Pains

Yes No

Apnea

Yes No

Arthritis/Rheumatism

Yes No

Artificial Heart Valve, Stent

Yes No

Artificial Joints

Yes No

Asthma

Yes No

Back Problems

Yes No

Bell's Palsy

Yes No

Bipolar Disorder

Yes No

Blood Disease

Yes No

Breathing Problems

Yes No

Brain Injury

Yes No

Bruise Easily

Yes No

Cancer

Yes No

Chemical Dependency

Yes No

Chemotherapy

Yes No

Circulatory Problems

Yes No

Congenital Heart Lesions

Yes No

COPD

Yes No

Cortisone Treatments

Yes No

Cough, persistent or bloody

Yes No

Depression

Yes No

Diabetes

Yes No

Dementia

Yes No

Down's Syndrome

Yes No

Eating Disorders

Yes No

Emphysema

Yes No

Epilepsy

Yes No

Fainting or dizziness

Yes No

Glaucoma

Yes No

Head/Neck/Jaw Injury

Yes No

Hearing Impaired

Yes No

Heart Attack

Yes No

Heart Disease

Yes No

Heart Murmur

Yes No

Hepatitis

Yes No

Herpes

Yes No

High Blood Pressure

Yes No

High Cholesterol

Yes No

Hypoglycemia

Yes No

Insomnia

Yes No

Jaundice

Yes No

Jaw Pain

Yes No

Kidney Disease

Yes No

Leukemia

Yes No

Liver Disease

Yes No

Low Blood Pressure

Yes No

Lung Disease

Yes No

Mental Disorders

Yes No

Mitral Valve Prolapse

Yes No

Nervous Problems

Yes No

Osteoporosis

Yes No

Pacemaker

Yes No

Psychiatric Care

Yes No

Radiation Treatment

Yes No

Renal Dialysis

Yes No

Respiratory Disease

Yes No

Rheumatic Fever

Yes No

Scarlet Fever

Yes No

Shingles

Yes No

Sickle Cell Disease

Yes No

Sinus Problems

Yes No

Special Diet

Yes No

STD/HPV

Yes No

Stomach/Intestinal Disease

Yes No

Stroke

Yes No

Swollen Neck Glands

Yes No

Thyroid Problems

Yes No

Tonsillitis

Yes No

Tuberculosis

Yes No

Tumor or growth on head or neck

Yes No

Ulcer

Yes No

Weight loss, unexplained

Yes No

Other Medical Conditions not listed:

Do you wear contact lenses?

Yes No

Women

Are you pregnant?

Yes No

If yes, please specify due date

Are you nursing?

Yes No

Taking birth control pills?

Yes No

Medications

List any medications you are currently taking and correlating diagnosis, including herbal supplements:

Allergies

If other, please specify

Notice of Privacy Practices

have had full opportunity to read and consider the contents of this Consent form and the Notice of
Privacy Practices. I understand that by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information
to carry out treatment, payment activities, and health operations.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Signature

Date

If this consent is signed by a personal representative (parent/guardian) on behalf of the patient, complete the following:

Personal Representative's Name

Relationship to Patient

Written Financial and General Office Policy

Thank you for choosing Silver Oaks Dentistry. Our primary goal is to provide you with individualized state of the art treatment in
a caring and comfortable atmosphere. An important part of that mission is making the cost of optimal care as easy and
manageable for our patients as possible by offering several payment options.

Payment Options

You can choose from:

Cash, Check, Visa, MasterCard, or Discover Card
Convenient Monthly Payment Plans* from CareCredit

Allows you to pay over time
No annual fees or pre-payment penalties Please

Please note

The patient portion of all services performed must be paid in full at the time of treatment unless prior arrangements have been approved. For plans requiring more than 2 appointments, alternative payment arrangements may be provided. If you choose to discontinue care before treatment is complete, your refund will be determined upon review of your case. All charges are your responsibility, whether your insurance company pays or does not pay. If any payment is made directly to you for services billed by Silver Oaks Dentistry, you recognize an obligation to promptly remit payment to Silver Oaks Dentistry.

We understand that financial problems may affect timely payment, so we encourage you to communicate any such problems to us, so that we may assist you in keeping your account in good standing. However, patients who default on their account will be referred to a collection agency or attorney by Silver Oaks Dentistry. You will be responsible for all costs of collecting monies owed, including court cost, collection agency fees, and attorney fees.

For patients with dental insurance, we are happy to work with your carrier to maximize your benefit and directly bill them for reimbursement for your treatment as a courtesy. Your insurance policy is a contract between you, your employer, and the insurance company. We are not a party to that contract. Our relationship is with you, not your insurance company. All treatment plans presented to you are an estimate of coverage based on the information provided to us by your insurance company, based on potential misinformation, your out of pocket cost could be more than our estimate. Any and all amounts not paid by the insurance company for services are your responsibility. Our office verifies benefits as a courtesy to our patients. A disclaimer is read to us by the insurance company when we verify benefits stating that benefits verified are not a guarantee of payment, claims will be reviewed for medical necessity and payments will be made based off the individual's plan.

Patients who arrive more than fifteen (15) minutes late for their scheduled appointment will have to RESCHEDULE their appointment for another day.

A fee of $50 is charged for patients who miss or cancel without 24-hour notice.

Silver Oaks Dentistry charges $25 for returned checks.

There is a $25 fee for copies of patient dental records.

If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.

I have read the above financial policy in full and insurance policies and agree to the same.

By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.

Patient, Parent or Guardian Signature

Date

Patient Name

* Subject to Credit Approval

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 slate 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 02/01/2016 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 students, 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 the 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 information to a family member, friend or another 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 (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 uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing 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 allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of healthcare information.

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

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

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 or 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 authorized federal officials health information required by lawful intelligence, counterintelligence, 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, or letter).

Patient Rights Access

You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot feasibly do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $1 .00 for each page, $0.00 per hour staff time to locate and copy your health information. and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)

Disclosure Accounting: You have the right to receive a list of instances in which our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12 month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

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, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, 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 US Department of Health and Human Services. We will provide you with the address to file your complaint with the US Department of Health and Human Services upon request.

Contact officer: Emanuel F. Dehelean, DMD

Address: 4719 Camino Dorado Dr, Ste 2, San Antonio, TX 78233

Telephone: (210) 656-4699

E-mail: silveroaksdentistry@yahoo.com