WELCOME TO OUR OFFICE

In order to make your dental care more personal and complete, we ask that you please complete the following information.

1. The undersigned hereby authorizes the doctor to take x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of the patient’s dental needs.
   
   
2. I also authorize the doctor to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment in connection with the patient. I understand that using anesthetic agents embodies a certain risk. Furthermore, I authorize and consent that the doctor chooses and employs such assistance as deemed fit to provide the recommended treatment.
   
   
3. I understand that all responsibility for payment for dental services provided in the office for my dependents and myself is mine, due and payable at the time services are rendered unless other arrangements have been made. In the event payments are not received by the agreed upon dates, I understand that a 1.5% finance charge (18% APR) may be added to my account, in addition to any collection charges. All returned checks are subject to a $30.00 return check fee.
   
   
4. I understand that where appropriate, credit bureau reports may be obtained.
   
   
5. I understand that it is my responsibility to advise your office of any changes in the information contained on this form.
   
   
6. At the office of Lakeside Dental Arts, we dedicate the appropriate time slot for your appointment in order to best take care of your needs. In return, we ask that if you are unable to keep your appointment please notify us at least 24 hours prior to your appointment time. Missed or last minute cancellations will result in a charge of $100.00.

7. In order to protect the privacy of other patients and staff and in compliance with federal and state privacy laws, the use of digital recordings by handheld devices such as smartphones are prohibited on the premises.

DENTAL INSURANCE INFORMATION

DENTAL INSURANCE COVERAGE NOTICE AND DISCLAIMER

Lakeside Dental Arts and their associates are committed to helping patients with their dental insurance.

1.       My dental insurance coverage is a contract between the insurance company and myself.

2.       My coverage is determined by my choice of dental insurance plan. Lakeside Dental Arts and their associates have no involvement with the insurance company fee allowances or payments.

3.       My dental insurance is not Lakeside Dental Arts’s responsibility. The practice will file my insurance as a courtesy to me. Lakeside Dental Arts is not responsible for delays in payment or determinations of coverage.

4.       I understand my dental insurance company may not communicate with Lakeside Dental Arts. I may need to contact Lakeside Dental Arts to inform them of any dental insurance issues.

5.       Lakeside Dental Arts and their associates cannot make ANY representation of warranty that my dental insurance company will cover all or any portion of the dental services provided.

6.       I understand it is my sole responsibility for payment of services regardless of my dental insurance coverage.

 

After reading this Notice and Disclaimer concerning my dental insurance coverage, I understand and agree to the terms and conditions above.

PATIENT INFORMATION

Our Practice, Lakeside Dental Arts, has always safeguarded and protected our valued patients personal and health information. These safeguards meet or exceed the 2003 H.I.P.A.A (Health Insurance Portability and Accountability Act), under the Department of Health and Human Services requirements to include the September 2013 "Omnibus" updated Privacy regulations. Our Practice Privacy policies, in accordance, allows us to use your personal information for "Normal and Customary" services when required communication within the health care profession, both clinical and administrative to include but not limited to: Consultations with another health care professional such as your medical doctor or another dental specialist about your treatment or progress, assisting with patient insurance, appointment reminders, account financial information and laboratory cases.

*Practice Use Only: Exemption(s) Declined, Patient Informed.

Who May We Release Information to- Please specify anyone you authorize our Practice to release information and what type of information we may give out, if requested and approved, about you, your treatment, progress or account. Usually this is a spouse or significant other, Parent or Guardian, Grandparents, adult children or whomever you choose to authorize our Practice and our health care Associates to release information to. 

PLEASE PRINT COMPLETE NAME(S) AND LEGAL RELATIONSHIP TO PATIENT.

I have read, reviewed and considered the contents of this Consent form and was given a  copy of the Practice's "Notice of Privacy Practices". I understand, that by signing this Consent form, I am giving my legal consent for your disclosure and use of mine and/or my dependents (Minor Child or other person(s) whom I am the legal guardian of) protected Private personal and health information in any form deemed needed in the Practice's professional judgment and in accordance with our normal and customary Privacy and Security practices. You have the legal right to amend or revoke this Consent given at any time by providing us written notice.

Medical/Dental History

Please select “YES” OR “NO” to indicate if you have had any of the following

MEDICAL/DENTAL HISTORY

I understand that the information I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest of confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.