LSD - New Patient Information Form

New Patient Information Form

Welcome to Let's Smile Dental!
Welcome to Let's Smile Dental! We require that you fill out this New Patient Information Form before your first appointment. You need to fill this out as thoroughly and accurately as possible so we may serve you to the best of our ability. This will take roughly 5-10 minutes to fill out.
Which department of Let's Smile Dental do you have an appointment with?*
Patient Information
Patient Name*

PrefixFirst NameMiddle NameLast Name
If different than your legal name, please specify the name you'd like to go by:
Nickname
Sex*
We need you biological sex for medicial consideration.
Patient's Birthdate*

MonthDayYear
Date
Patient's Age*
Marital Status*
Patient's Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Email Address*
example@example.com
Social Security Number
We will need this to verify the patient's information with their insurance.
Employer
Relevant Hobbies/Activities
Names of other family members seen at Let's Smile
This page is not required for Orthodontic patients.
Parent / Guardian Information

This only must be filled out if the patient is under 18 years of age.

This must only be filled out if the patient is under 18 years of age.
Primary Provider's Full Name*

First NameLast Name
Relationship to Child*
Home Phone Number*
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Primary Provider's Email Address*
example@example.com
Will this person be the financially responsible provider? *
Will this person be the provider responsible for setting up appointments? *
Home Address (If different than on the Patient's Information)

Street Address

Street Address Line 2

CityState

Zip Code
Primary Provider's Social Security Number*
Primary Provider's Employer
Secondary Provider's Full Name

First NameLast Name
Relationship to Child
Home Phone Number
Please enter a valid phone number.
Cell Phone Number
Please enter a valid phone number.
Work Phone Number
Please enter a valid phone number.
Secondary Provider's Email Address
example@example.com
Will this person be the financially responsible provider?
Will this person be the provider responsible for setting up appointments? *
Home Address (If different than on the Patient's Information)

Street Address

Street Address Line 2

CityState

Zip Code
Secondary Provider's Social Security Number
Secondary Provider's Employer
How did you hear about Let's Smile Dental? *
If from a friend, please add their name.

Release and Waiver

Our office is committed to meeting or exceeding the standards of infection control mandated by OSHA, the CDC, and the ADA.
I authorize release of any information regarding the patient dental treatment to my dental and/or medical insurance company. *

Clear
Date of Signature*

MonthDayYear
Date
I have read the above questions and understand them. I will not hold the dentist, orthodontist, oral surgeon or any member of his/her staff responsible for anyerrors of omissions that I have made in the completion of this form. I will notify the dentist, orthodontist, or oral surgeon of any changes in the patient medical ordental health. I also authorize the dental staff to perform the necessary dental services the patient may need.*

Clear
Date of Signature*

MonthDayYear
Date

HIPPA NOTICE OF PRIVACY ACT

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

PLEASE REVIEW CAREFULLY

How we may use and disclose your health information

1.        Treatment: We may use and disclose Health Information for your treatment and to provide you with treatment related health care services.

2.        Payment: We may use and disclose Health Information so that we or others may bill and receive payment from you, insurance company, or a third party for the treatments and services you received.

3.        Health Care Operations: We may use and disclose Health information for health care operation purposes. These uses and disclosures are necessary to mak sure that all our patients receive quality care and to operate and manage our office.

4.        Appointment reminders, treatment alternatives, and health related benefits and services: We may use and disclose Health information to remind you of your appointment.

5.        Individuals involved in your care or payment of your care: We may share Health Information with a person involved in your medical care or payment for your care. Such as family, your close friends, or guardian.

6.        Research: under certain circumstances, we may use and disclose your Health information for research purposes.

SPECIAL SITUATIONS

As Required by Law: we may disclose Health Information as required by international, federal, state, or local law.

To Avert a Serious Threat to Health or Safety: We may use and disclose Health Information when necessary to prevent a serious threat to your health and safety or the safety and health of public or another person.

Business Associates: We may use and disclose Health Information to our business associates who function on our behalf or provide us with services such as billing.

Organ and Tissue Donation: If you are an organ donor, we may use or release Health Information to an organization that handles organ procurement, banking or transportation.

Military and Veterans: If you are a member of the armed forces, we may release Health Information as required by military command authorities.

Workers' Compensation: We may release health information for workers' compensation or similar programs.

Public Health Risks: We may disclose Health Information for public health activities. These activities generally include disclosures to prevent or control disease, injury or disability; report birth and deaths; report child abuse or neglect; report reactions to medication or problems with products; notify people of recalls of products they may be using; inform a person who may have been exposed to a disease or condition; and report to appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

Health Oversight Activities: We may disclose Health Information to health oversight agency for activities authorized by law.

Lawsuits and Disputes: If you are involved in a lawsuit or dispute, we may disclose Health Information in response to administrative order. We also may disclose Health Information in response to a subpoena, discovery request, or other lawful process by someone else involved in the dispute, but only if efforts have been made to tell you about the request or to obtain an order protecting the information requested.

Law Enforcement: We may release Health Information if asked by a law enforcement official if the information is: 1) in response to a court order, subpoena, warrant, summons, or similar process; 2) limited information to identify or locate a suspect, fugitive, material witness, or missing person; 3) about the victim of a crime even if, under certain very limited circumstances, we are unable to obtain the person's agreement; 4) about a death we believe may be the result of criminal conduct; 5) about criminal conduct on our premises; and 6) in an emergency to report a crime, the location of the crime or victims, or the identity, description, or location of the person who committed the crime.

Coroners, Medical Examiners, and Funeral Directors: We may release Health Information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We also may release Health Information to funeral directors as necessary for their duties. National Security and Intelligence Activities: We may release Health Information to authorized federal officials for intelligence, counterintelligence, and other national security activities authorized by law.

Protective Services for the President and Others: We may disclose Health Information to authorize federal officials so they may provide protection to the president, other authorized persons or foreign heads of state, or to conduct special investigations.

Inmates or Individuals in Custody: If you are an inmate of a correctional institution or under the custody of a law enforcement official, we may release Health Information to the correctional institution or law enforcement official. This release would be made if necessary: 1) for the institution to provide you with health care. 2) to protect your health and safety or the health and safety of others, or 3) for the safety and security of the correctional institution.

Your Rights

You have the following rights regarding Health Information we have about you:

Right to Inspect and Copy: You have the right to inspect and copy Health Information that may be used to make decision about your care or payment of your care.

This includes medical and billing records. To inspect and copy this Health Information, you must make your request, in writing, to Let’s Smile Dental.

Right to Amend: If you feel that Health Information, we have is incorrect, or incomplete, you may ask us to amend the information. You have the right to request an amendment for as long as the information is kept by or for our office. To request an amendment, you must make your request, in writing, to Let’s Smile Dental. Right to an Accounting of Disclosures: You have the right to request a list of certain disclosures w made of Health Information for purposes other than treatment, payment, and health care operations for which you provided written authorization. To request an accounting of disclosures, you must make your request, in writing, to Yes Braces.

Right to Request Restrictions: You have the right to request a restriction of limitation on the Health Information we use or disclose for treatment, payment, or health care operations. You also have the right to request a limit on the Health Information we disclose to someone involved in you care or the payment for your care, such as a family member or friend. To request a restriction, you must make your request, in writing, to Let’s Smile Dental. We are not required to agree to your request. If we agree, we will comply with you request unless the information is needed to provide you with emergency treatment.

Right to Request Confidential Communication: You have the right to request that we communicate with you about the medical matters in a certain way or at a certain location. For example, you can ask that we contact you only by mail or at work. To request confidential communication, you must make your request, in writing, to Let’s Smile Dental. Your request must specify how or where you wish to be contacted. We will accommodate reasonable request.
Let's Smile Dental HIPPA Consent Form
The Health Insurance Portability and Accountability Act of 1996 (HIPAA) does not require that health care providers obtain a consent agreement as it relates to the use and disclosure of individually identifiable health information (IIHI), but many practices will continue to use the Consent Agreement for other purposes. Though it is not necessary to have your consent to allow us to use or disclose your IIHI to others who will treat or you support in providing you quality health care services, it is important to have your consent to use or disclose your IIHI to health care plans to ensure accurate and timely payment for the services rendered. The law requires that we inform you of our policy regarding the protection of your IIHI through our Privacy Notice We may already have a consent agreement from you. Please refer to our Privacy Notice for a full explanation of how this office will protect your individually identifiable health information (IIHI).

The following is a statement that allows us the necessary latitude to work within the new requirements.

I,blanks* (Responsible Party/Patient Name) have been presented with a Privacy Notice explaining my rights regarding my individually identifiable health information (IIHI). I consent to the use and/or disclosure of my IIHI for purposes of treatment. payment, or other health care operations (TPO)_ Other uses of my IIHI will require authorization from me for the specific intention of disclosure.
Privacy Notice

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

My signature indicates that I have received a copy or have been asked about receiving a copy of the privacy notice.
Date of Signature*

MonthDayYear
Date
Patient or Responsible Party Signature*

Clear

This only needs to be completed if the patient is under 18 years of age.
Parental Consent Form

Needed only for Patients Under 18 Years Old

Note: At Let’s Smile Dental, we value and appreciate our patients as well as their parents and guardians. To keep our workflow as efficient and as safe as possible, we have updated our policies with regards to who may bring a patient for an appointment:

•       If a child under the age of 18 presents by themselves without the parent or legal guardian, we will have to reschedule their appointment. Phone calls will not be accepted as confirmation of parental supervision.

•       If a parent or guardian is unable to be present at the time of the appointment, you may have an individual that is 18 years or older accompany your child if they are listed below, OR have filled out the parental consent form in-practice.

•       For new patient appointments, the legal parent or guardian must be present at the first appointment.
Do you plan on having someone other than a parent/legal guardian bring your child to their appointments?*
Please list all children below:
Authorized Caregiver's Name:*

First NameLast Name
Relationship to Children
Caregiver's Phone Number
Please enter a valid phone number.
By signing below, I give permission for the above name caregiver to be authorized to accompany the abovenamed child(ren) for their orthodontic appointments and subsequent recall visits. Treatment to be performed includes routine orthodontic services outlined during the initial consultation appointment. The initial patient registration package, all medical history/dental history must be filled out by parent or legal guardian. This consent shall be effective from date of signature until revoked by parent or legal guardian.
Parent / Guardian Full Name*

First NameLast Name
Parent / Guardian Signature*

Clear

New-Patient Policies
Financial Policy

Payment is due the date services are rendered. Our office submits claims to your insurance as a courtesy, Any portion of the insurance balance that is left unpaid by the insurance company will default to the responsible party. Our office will contact you should this occur. After 90 days all accounts that are not paid in full may be sent to a third-party collection agency. Any accounts turned over to collections will be assessed a collection fee of 30%.
Signature of Responsible Party*

Clear
Date of Signature*

MonthDayYear
Date
Cancellation Policy

I acknowledge that I will be responsible for the fees that follow for a broken or no-show appointment if the 24-hour prior cancellation notice is not given.

Fees
- $50 Pediatric / Orthodontic Routine Appointment
- $75 Restorative
- $100 Oral Sedation
- $200 General Anesthesia
Signature of Responsible Party*

Clear
Date of Signature*

MonthDayYear
Date
Photo Release Form

I hereby grant permission to Let's Smile, PC to use my/my child's photograph and/or video in any marketing, advertising, or teaching materials used to market or advertise the practice, including use on their website and/or social media sites.

I acknowledge the practice's right to crop or otherwise treat the photograph or video at their discretion. I also acknowledge that the practice may choose not to use my photograph and/or video now but may do so at their discretion later.

I also understand that once my image is posted on the website, the image can be downloaded by any computer user, which is beyond the control of the practice. I will hold the practice and any affiliated offices harmless from any such use or download.
Please make a selection*
Signature of Responsible Party*

Clear
Date of Signature*

MonthDayYear
Date
Should be Empty:

New Patient Information Form

Patient Information

Parent / Guardian Information

Dentist Information

Medical Insurance and Medical History

Dental Insurance and History

Release and Waiver

Let's Smile Dental HIPPA Consent Form

New-Patient Policies