Dental Health PC & Complete Dental Health LLC

Health History

(Confidential)

(Please fill out all of the forms)

General Information

Person Responsible for Account if other than yourself

Primary Insurance

Secondary  Insurance

Dental History
 

Do you have or have you ever had any of the following?

Indicate which you use and how often
 

Bristle Brush: Hard, Medium, Soft

Have you had or do you have any of the following medical conditions 

Are you allergic to any of the following

Please list  other allergies 

Chemical Dependency 

Women
 

With regards to oral contraceptives it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance.
 

 

AUTHORIZATION AND RELEASE

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to my family or me during the period of such dental care to third party payers and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I understand I am responsible for paying all services rendered at Dental Health PC or Complete Dental Health. I agree to be responsible for payment of all services rendered on my behalf or my dependents. I am aware there are no service fees for 60 days. After that time the interest rate is at 18% annually with a minimum service fee of $5.00 per month for invoices.

Dental Health PC & Complete Dental Health LLC

CONSENT TO PERFORM DENTISTRY

(Please fill out all of the forms)

1. I hereby authorize and direct the dentists Kendall S. Wood DDS or Matthew C. Schapper DMD and/or dental auxiliaries of his choice, to perform the following dental treatment or oral surgery procedure(s), including the use of any necessary or advisable local anesthetics, radiographs (x-rays) or diagnostic aids.
   • Preventative hygiene treatment (prophylaxis) and the application of topical fluoride.
   • Application of "sealants" to the grooves of the teeth.
   • Treatment of diseased or injured teeth with dental restorations (fillings and crowns).
   • Replacement of missing teeth with dental prostheses. (bridges, partial dentures, full dentures)
   • Removal (extraction) of one or more teeth.
   • Treatment of diseased or injured oral tissues (hard and/or soft)
   • Use of nitrous oxide to control apprehension or disruptive behavior.
   • Treatment of malposed (crooked) teeth and/or oral developmental or growth abnormalities.
   • Use of local anesthetic to accomplish necessary treatment.
   • Adjustment of the contours of teeth to correct malocclusion (poor bite position).
2. I understand that there are risks involved in dental treatment and hereby acknowledge that these risks will be explained to me, that I will have an opportunity to ask questions regarding the treatment and the risks, and that I fully understand the same.
3. I agree to the use of local anesthetic and/or the use of nitrous oxide/oxygen analgesia depending on the judgment of the doctor and hygienists. Nitrous oxide/oxygen may occasionally produce nausea and vomiting. I am also aware that the nosepiece may leave an indentation or ring around the nose, which disappears shortly after the procedure. I understand and have been informed of the above risks and complications.
4. I recognize that during the course of treatment unforeseen circumstances may necessitate additional or different procedures from those discussed. I therefore authorize and request the performance of any additional procedures that are deemed necessary or desirable to oral health and well being in the professional judgment of the dentist.
5. There are possible risks and complications associated with the administration of local anesthesia, sedation and drugs. The most common of these are swelling, bleeding, pain, nausea, vomiting, bruising, paresthesia, bleeding at or near the injection(s) site, fainting, lip and cheek biting resulting in ulceration and infection of the mucosa. I also understand that there are rare potential risks such as unfavorable reactions to medications in respiratory and cardiovascular collapse (stopping of breathing and heart function) and lack of oxygen to the brain that could result in coma or death. I understand and have been informed of the above risks and complications.
6. I authorize the doctor to use photographs, radiographs, other diagnostic materials and treatment records for the purposes of teaching, research, scientific publications, and website as well as in office video screen.
7. I will be advised that the success of the dental treatment to be provided will require that the patient and the parents follow post-operative and post-care instructions of the dentist. I agree that the success of the treatment requires that all post­operative and post-care instructions be followed and that regular office visits as scheduled by my dentist and his auxiliaries must be maintained.
8. I hereby state that I have read and understand this consent, and that all questions about the procedures will be answered in a satisfactory manner; and I understand that I have the right to be provided answers to questions which may arise during and after the course of my treatment.
9. I further understand that this consent will remain in effect until such time that I choose in writing to terminate it.
10. I understand that I have the right to deny such procedures after PARQ (Patient Advised of Risks and Questions were addressed). I knowingly take on all risks to my personal health with no liability to the dentist or any auxiliary when denying recommended dental treatment.

Financial Policy Dental Health PC & Complete Dental Health LLC

Kendall S. Wood DDS & Matthew C. Schapper DMD

This statement is to inform you of our financial policy. We are committed to providing you with the highest quality care using only the best material and technology available in the market today. We are also committed to providing you with current information and educational tools so that you may fully participate in maintaining optimum oral health. Our financial policy is intended to facilitate excellent service to you while minimizing our administrative costs.

Your patient portion is due at the time the service is provided. Our office accepts cash, personal checks, Debit cards, MasterCard, Visa, American Express and Discover.

All charges you incur are your responsibility regardless of your insurance coverage. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your employer, and the insurance company. Our office is not a party to that contract. In order for our office to help file your insurance claim, you must give us current insurance information anytime your insurance carrier changes.

As a courtesy to you we will help you process your insurance claim. Insurance payments ordinarily are received within 30-45 days from the time of billing. If your insurance company has not made payment to our office within 60 days, we will ask you to pay the balance due. You will be responsible for seeking reimbursement from your insurance company at that time. Our office does not guarantee that your insurance company will pay for treatment you receive from our practice. We will bill insurance for the treatment that is rendered. However, if your claim is denied, you will be responsible for paying the full amount at that time.

Our office will not enter into a dispute with your insurance company over any claim, although we will provide the necessary documentation that your insurance company may request to sort out any confusion or questions that may arise. It is ultimately your responsibility to resolve any type of dispute over payments made or not made by your insurance company.

We will be happy to provide you with an ESTIMATE of what your patient portion will be for any treatment plan that is recommended. The estimate is not a guarantee of payment from your insurance company. All treatment plan prices will be honored for 30 days.

We reserve the right to charge a $40/appt minimum fee for any dental appointment that is missed or cancelled without a minimum of 24 hours advance notice.

Returned checks and balances older than 60 days are subject to collection fees up to $100 and finance charges at the rate of 1.5% per month or 18% annually with a minimum service fee of $5.00

If you have any questions regarding our financial policy, please ask. We are committed to providing you with the most positive experience in dental care.

Dental Health PC & Complete Dental Health LLC

Consent for Use and Disclosure of Health Information
 

Children(s)  

Please fill out this section if someone other than yourself can acquire information or pay on your account:
 

I understand that by signing this form I will consent to use and disclosure of my protected health information to carry out treatment, payment activities, and healthcare operations.

Before I sign, I have the right to read and/or request the Notice of Privacy Practices. This notice provides a description of our: treatment, payment activities, health care operations, the uses and disclosures we may make of your protected health information, and other important matters about your protected health information.

I understand that I have the right to revoke this authorization at any time. I understand that in order to revoke this authorization, I must do so in writing and present my written revocation to the contact person mentioned below. I understand that the revocation will not apply to information that has already been disclosed in response to and in reliance on this authorization.

Contact Person:

We have attempted to obtain written acknowledgement of receipt of our Privacy Practices but acknowledgement could not be obtained due to: