Primary Dental Insurance

Secondary Dental Insurance

Health History

Correct answers to the following questions will allow your dentist to treat you on a more individual basis, providing the care appropriate for your particular needs.

Medical History

Women: Are you

Aids/HIV Positive
Cortisone Medicine
Renal Dialysis
Alzhelmer's Disease
Hepatitis A
Rheumatic Fever
Drug Addiction
Hepatitis B & C
Easily Winded
Scarlet Fever
High Blood Pressure
Epilepsy or Seizures
Hives or Rash
Sickle Call Disease
Artificial Health Value
Exeessive Bleeding
Sinus Trouble
Artificial Joint
Excessive Thirst
Irregular Heartbeat
Spina Bifida
Fainting Spells/Dizziness
Kidney Problems
Stomach/Intestinal Disease
Blood Disease
Frequent Cough
Blood Transfusion
Frequent Diarrhea
Liver Disease
Swelling of Limbs
Beathing Problem
Frequent Headaches
Low Blood Pressure
Thyroid Disease
Bruise Easily
Genital Herpes
Lung Disease
Mitral Valve Prolapse
Hay Fever
Pain in Jaw Joints
Tumors or Growths
Chest Pains
Heart Attack/Failure
Parathyroid Diesease
Cold Sores/Fever Blisters
Heart Murmur
Psychiatric Care
Venereal Diesease
Congenital Heart Disorder
Heart Pace Maker
Radiation Treatments
Yellow Jaundice
Heart Troble/Diesease
Recent Weight Loss
To the best of the knowledge, the questions on this form have been accurately answered. I understand that providing incorrect infotmation can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Dental Office Informed Consent

It is important to us that you, our patient, understand the treatment we are recommending and any invasive procedures we may, with your agreement, perform. We want to involve you in all decisions concerning invasive procedures you may need. We take informed consent very seriously in our office. Therefore, we only want you to sign this form when you understand that there is a risk associated with dental procedures, and all your questions have been answered.
Dental treatment and procedures are not to be taken for granted as being routine or without risk for complications. As with all medical treatment to one's body, including dental treatment, there are no guarantees that the results will be as planned and to each individual's satisfaction. When dealing with the human body there are potentially many variables, some predictable and others are not. Complication rates in dentistry are low but do exist. Even a minor procedure like "filling" can lead to major complications that cannot be foreseen. For example, "Novacaine" injection could lead to allergic reaction, anaphylaxis, facial hemorrhage, swelling, bruising, and even hospitilization or death. Granted these are fairy uncommon occurrences but individuals who are contemplating this should be aware of this prior to consenting. Whenever drilling is invloved, even a simple cavity can lead to pulpal (nerve) problems, abscess, fractured tooth, and/or post treatment pain to biting and to temperature extremes (hot and cold). These complaints can be transient or may persit requiring further treatments. The above examples are only samples of possible complications with dental treatment and are not limited to these. In general, complications include but are not limited to pain, swelling, bleeding, infection, and other nerve problems.

I have read, understand and consent to dental treatments.

Notice of privacy practices patient acknowledgement

I have received this practice's Notice of Privacy Practices written in plain language. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights, how I may exercise these rights, and the practice's legal duties with respect to my information. I understand that this practice reserves the right to change the terms of its Notice of Privacy Practices, and to make changes regarding all protected health information resident at, or controlled by, this practice. I understand I can obtain this practice's current Notice of Privacy Practices on request.

Office Policy

Cancellations and Broken Appointments

We feel that our patient's time is valuable. When your appointment is made, a room is reserved, your records are prepared, and special instruments are readied for your visit. Except for emergency treatment for another patient, you can except us to be prompt. We, of course, would appreciate the same courtesy from you. The change will be $50.00 for every thirty minutes of appointment time. We understand that extreme or unavoidable emergencies or circumstances do arise which may require you to change you appointment, this will take into consideration.

Financial Policy

Check returned from the bank are subject ta a $35 service fee. Account delinquent more than 30days from, the date of billing are subject to a 12% per month (12% annually) finance changes, unless prior arrangements have been made with the office attorney's fees.
Thanks you for choosing our office. We want to provide you with the best dental care possible. If you have any questions regarding our policies and your treatments, please do not hesitate to ask.



The Health Insurance Portability and Accountability Act of 1996(HIPAA) requires all health care records and other individually identifiable health insurance used or disclosed to us in any form, whether electronically, on paper, or orally, be kept confidential. This federal law gives you, the patient, significant new rights to understand and control how your health information is used. HIPAA provides penalties for covered entities that misuse personal health information. As required by HIPAA, we have prepared this explaination of how we are required to maintain the privacy of health information and how we may use and disclose your health information.
Without specific written authorization, we are permitted to use and disclose your health care records for the purposes of treatment, payment and health care operations.
Treatments means providing, coordinating or managing health care and related services by one or more health care providers. For example, we may need to share information with other providers or specialists involved in the continuation of your care.
Payment means such activities as obtaining reimbursement of sevices, confirming coverage, billing or collection activitiy and utilization review. For example, we disclose treatment information when billing a dental plan for your dental services.
Health Care Operations include the business acpects of running our practice. For example, patient information may be used for traning purposes or quality assessment.
Unless you request otherwise, we may use or disclose health information to your family member, friend or other personal representative to the extent neccessary to help with your healthcare or payment for your healthcare. In addition we may use your confidential information to remind you of appointments by sending reminder postcards and/or leaving messages at home and/or work. Any other uses or disclolure will be made only with your written authorization. You may revoke such authorization in written and we are required to honor and abide by that written request, except to the extent that we have already taken action relaying on your authorization. You have certain rigths in regards to your protected health information, which you can excersice by presenting a written request to our Privacy Officer at the practice address listed below:
  • The right to request restriction on certain uses and disclosure of protected health information, including those related to disclosures to family members, other relatives, close personal friends, or any other persnal identity by you. We are, however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by us unless you agree in written to remove it.
  • The rigth to access, inspect and copy your protected health information.
  • The right to request an amendment to your protected health information.
  • The right to receive an accounting of disclosures of protected health information outside of treatment, payment and health care operations.
  • The right to obtain a paper copy of this notice from us upon request.
We are required by law to maintain the privacy of your protected health inforamtion and to provide you with notice of our legal duties and privacy practices with respect to protected health information.
This notice is effective as of 14 April 2003 and we are reuired to abide by the terms of the Notice of Privacy Practices currently in effect. We reserve the right to change the term of our Notice of Privacy Practices and to make the new notice provisions effective for all protected health information that we maintain.
Revisions to our Notice of Privacy Practices will be posted on the effective date and you may request a written copy of the Revised Notice from this office.
You have the right to file a formal, written complaints with us at the address below, or the Department of Health & Human Services,Office of Civil Righs, in the event you feel your privacy rights have been voilated. We will not retaliate against you for filing a complaint.

For more information about our Privary Practices, please contact:

Privacy Officer:


For more information about HIPAA or to file a complaint:

The U.S. Dept. of Health & Human Services
Office of Civil Rights
200 Independence Avenue, S.W.
Washington D.C. 20201
877-696-6775 (toll-free)