Please check the box of any condition you have or may have had.
1. Have you had an unfavorable dental experience?
2. Have you ever had complications from past dental treatment?
3. Have you ever had trouble getting numb or had any reactions to local anesthesia?
4. Do you have, or have you had any teeth removed or teeth that never developed?
5. Did you ever have orthodontic treatment, braces, or your bite adjusted?
6. Do your gums bleed or do they hurt during brushing/flossing?
7. Have you ever been told you have gum disease or are losing bone around your teeth?
8. Have you ever noticed an unpleasant taste/smell in your mouth?
9. Does anyone in your family have a history of periodontal/gum disease?
10. Have you experienced gum recession (teeth look longer)?
11. Have you ever had any teeth become loose on their own?
12. Have you had any cavities within the past 3 years?
13. Does the amount of your saliva in your mouth seem to little or do you have trouble eating/swallowing food?
14. Do you feel or notice any holes on the tops of your teeth?
15. Are your teeth sensitive to hot, cold, biting, sweets, etc or do you avoid brushing any area?
16. Do you have grooves or notches on your teeth near the gum line?
17. Have you ever broken, chipped, cracked any teeth or had a toothache?
18. Do you get food caught between your teeth?
19. Do you have problems with your jaw joint? (pain, popping, cracking, locking, etc.)
20. Do you avoid chewing gum, carrots, nuts, hard or chewy foods?
21. Have your teeth changed in the last 5 years, become shorter, thinner or worn?
22. Are your teeth becoming more crooked, crowded, or overlapped?
23. Are your teeth developing spaces or becoming loose?
24. Do you have more than one bite, squeeze, or shift your jaw to make your teeth fit together?
25. Do you clench your teeth during the day or night or wake with a headache?
26. Do you wear, or have you ever worn, a bite appliance?
27. Is there anything about your appearance of your teeth that you would like to change?
28. Have you ever whitened/bleached your teeth?
29. Have you felt uncomfortable or self-conscious about the appearance of your teeth?
30. Have you been disappointed with the appearance of previous dental work?
AppleWhite Dental Iowa, P.C., dbaWestown Pediatric Dentistry4090 Westown PkwyWest Des Moines, IA 50266(515) 267-0737
I acknowledge that I have received a copy of the Notice of Privacy Practices for Westown Pediatric Dentistry. The Notice of Privacy Practices describes the types of uses and disclosure of my protected health information that might occur in my treatment, payment for services, or in the performance of the office health care operations. The Notice of Privacy Practices also describe my rights and the responsibilities and duties of CORDENTAL Group with respect to my protected health information. The Notice of Privacy Practices is also posted in the facility. Westown Pediatric Dentistry reserves the right to change the privacy practices that are described in the Notice of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Notice of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Notice of Privacy Practices by requesting that one be mailed to me.
ADDITIONAL DISCLOSURE AUTHORITY
In addition to the allowable disclosures described in the Notice of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below.
ANY MEMBER OF MY IMMEDIATE FAMILY
MY SIGNATURE BELOW ACKNOWLEDGES I HAVE RECEIVED A COPY OF THE NOTICE OF PRIVACY PRACTICES. ALL OF MY QUESTIONS HAVE BEEN ANSWERED AND I UNDERSTAND THAT I MAY MAKE INQUIRY TO THIS ACKNOWLEDGEMENT AND/OR CHANGES IN THE ADDITIONAL DICLOSURE AUTHORITY AT ANY TIME.
2019-09 Acknowledgement Notice of Privacy Practices – Westown Pediatric Dentistry, an affiliate of CORDENTAL Group
I consent to receive dental services, including examination, dental prophylaxis (cleaning) and routine fillings from Westown Pediatric Dentistry (the “PRACTICE” I understand that the initial visit may require radiographs to complete the examination, diagnosis and treatment plan. I understand I will be provided a treatment plan for necessary services; however, I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I give my permission to my treating dentist to make any/all changes and additions as necessary. I further understand that clicking, popping, and pain in the jaw joint may occur as a normal part of treatment; however, should the discomfort become intolerable, I may be referred to a specialist for treatment, the cost of which is my responsibility.
I understand that the practice and my treating dentist cannot guarantee treatment outcomes. I am responsible for reviewing the treatment plan and asking any questions I may have prior to receiving treatment. I have the right to accept or reject treatment recommended by my treating dentist. By consenting to my dentist’s treatment plans, I acknowledge that I accept known risks and complications of such treatments. It is my responsibility to fully inform the dentist of my medical history, all medications or other drugs that I am using and otherwise truthfully answer all questions related to my care. It is also my responsibility to follow my dentist’s pre- and post-treatment instructions and oral care instructions. I acknowledge that failure to comply with these requirements may increase the chance of poor treatment outcomes.
I agree that, when I provide my landline or cell phone number(s), I am giving you express consent to contact me at these numbers, or at any number that is later acquired for me and to leave live or pre-recorded messages to voicemail or text, regarding scheduling or scheduled appointments, my services, or my bill. For greater efficiency, calls or texts may be delivered by an auto-dialer. I realize that as a consequence of providing this consent I may receive future calls or text messages that deliver pre-recorded messages by or on behalf of the practice. I will be responsible for all data and other charges for text or email messages. Providing a telephone or cell number or email address is not a condition of receiving services. This consent to receive voicemails, emails and text messages applies to future communications unless I request a change in writing, by clicking an unsubscribe link provided in emails, or by replying STOP to all text communications. I further acknowledge that these communications may contain information that is protected under state and federal privacy laws, and that my consent means that THE PRACTICE may use the methods I identify below to contact me about appointments, my dental treatment, payments and other information that may contain protected health information. THE PRACTICE will use all reasonable efforts to minimize the amount of protected health information disclosed and otherwise protect my personal data; however, I am aware that such communications will not be encrypted and that there may be some risk that such messages may be read or accessed by a third party. By signing below my acceptance to receive communications via text, email or voicemail, I am agreeing that I have been informed of this risk and that I still prefer to receive communications in these manners.
CONSENT TO PHOTOGRAPH
I understand photographs, videotapes, digital and/or other images may be made/recorded for identification, treatment and payment purposes. These will be part of my record and will not be used for any marketing or other purposes. I will specifically authorize in writing any other use or disclosure of any image or recording.
CONSENT TO SCHEDULING AND APPOINTMENTS
I understand that it is my responsibility to change or cancel appointments I can no longer keep at least 2 business days prior to the scheduled appointment. If I do not do so, the Practice may charge me a cancellation fee of up to $100 per scheduled hour. I further understand that multiple short notice cancellations may result in my dismissal as a patient.
PAYMENT FOR SERVICES
I understand that I am responsible for all charges for the care I receive. If I do not have dental insurance coverage, I will pay all amounts for which I am responsible in full, in advance of treatment. It is my responsibility to provide accurate and up-to-date information regarding my dental insurance coverage. I agree that payments from my dental plan may go directly to the practice. If I should receive the payments, I understand that I will be responsible for immediately paying such amounts to the practice. Depending on the type of coverage I have, my responsibilities are as follows:
IN NETWORK: If my treating dentist is in-network with my dental insurance plan, I will be billed pursuant to the terms of my insurance policy and my dentist’s contract with the insurer. Even when the practice and my treating dentist are a participating provider with my insurance, I understand that the practice may hold me responsible and collect all charges in any one of the following situations:
OUT OF NETWORK: If my treating dentist is not a participating provider with my insurance, I will be required to pay for all treatment in full, in advance. The practice may file for insurance coverage as a courtesy and apply anything they pay towards my account. If payment from my insurance company results in an overpayment on the account, I will be reimbursed by the practice.
ALL PAYORS: Regardless of whether my treating dentist is participating provider, I will be responsible for any deductibles, co payments, the costs of uncovered services and any other part of the bill that my dental plan says I must pay. If for any reason I do not pay, in full, the amounts I owe the practice, I will also reimburse the practice for all costs of collection, including legal fees and a 25% collection fee of the total amount submitted to the collection agency. I also agree the practice may charge me interest equal to 2% monthly on all balances that have been outstanding for thirty (30) days or more.
RELEASE OF INSURANCE BENEFITSI agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless prohibited by law or the treating dentists or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted by law, I consent to CORDENTAL Group’s use and disclosure of my protected health information to carry out payment activities in connection with insurance claims. I hereby authorize and direct payment of the insurance benefits otherwise payable to me, directly to CORDENTAL Group and its partnered affiliates.
MY SIGNATURE BELOW ACKNOWLEDGES THAT I HAVE READ THIS CONSENT AGREEMENT AND AGREE TO THE STATED ITEMS AS THEY HAVE BEEN OUTLINED. I HAVE BEEN GIVEN THE OPPORTUNITY TO HAVE MY QUESTIONS ANSWERED AND UNDERSTAND THAT I MAY MAKE INQUIRY TO THIS AGREEMENT AT ANY TIME. I FURTHER ACKNOWLEDGE THAT I MAY REVOKE MY CONSENT TO ALL OR ANY PART OF THIS CONSENT AGREEMENT AT ANY TIME BY DOING SO IN WRITING.