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  • English (US)
  • Patient Information Form (Adult)

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  • Emergency Contact Information

  • Billing Information / Responsible Party

  • Dental Insurance Information

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  • Dental History

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  • Medical History

  • Wrapping Up

  • I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform the 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.

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  • Patient Consent to Use and Disclosure Information for Treatment, Payment, and Health Care Operations

  • I, as the above stated patient understand that as part of my heath care, Dr. L. Ruth Berry, D.M.D., P.A. originates and maintains paper and/or electronic records describing my health history, symptoms, examinations, and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:

    • A basis from planning my care and treatment.
    • A means of communication among the dental professionals who contribute to my care, such as referrals. 
    • A source of information for applying my disagnoses and treatment information to my bill.
    • A means which a third-party can verify that services billed were actually provided.
    • A tool or routine operations, such as assessing quality reviewing the competence of staff.

    I have been provided with a Notice of Patient Privacy Practices that provides a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

    • The right to view Notice prior to signing this consent
    • The right to restrict or revoke the use or disclosure of my health information for other uses or purposes, and 
    • The right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations, treatment, payment.
  • Please tell us with whom we may discuss your treatment, payment or healthcare operations:

  • I further understand that Dr. L. Ruth Berry, D.M.D., P.A. reserves the right to change her notice and practices per Section 164.520 of the Code of Federal Regulation. Should Dr. L. Ruth Berry, D.M.D., P.A., change her notice, I may request a copy of any revised notice in person (or by U.S. mail, to be sent to the address I have provided).

  • Appointment Reminders:

  • As part of treatment, payments, or healthcare operations, it may become necessary to disclose health information to another entity (i.e., referrals to other healthcare providers). I consent to such disclosure for these use as permitted by law.

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  • Photographic Waiver and Consent

  • So that we may provide you with the best possible state-of-the-art orthodontic services available, we feel it is necessary to take photographs. We would appreciate you taking the time to read and sign this consent form. 

    I hereby permit L. Ruth Berry, D.M.D., P.A., Dr. L. Ruth Berry, or any staff she may designate to take photographs for diagnostic purposes and enhance dental records. I agree that these photographs will remain the property of Dr. L. Ruth Berry.

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