New Patient

At Truly Yours Family Dental, we understand your time is important and in result, we have reserved time for your visit with us. In the event you need to make changes to the appointed time, we request at least 48 business hours (2 business days) notice. To maintain quality of care and keep from overbooking, our office requires such notice, otherwise a $75 NO SHOW FEE will apply. We understand that emergencies and illness may arise last minute, but please do give us enough time so that we may allow other patients to use that reserved time.

By signing below, you acknowledge you have listed all pertinent information, read and understand our Cancellation Policy and have had opportunity to review or receive a copy of our Privacy Practices.

Although dental personnel primarily treat the are in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Please answer the questions to the best of your knowledge.

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient’s) health. It is my responsibility to inform the dental office of any changes in medical status.

Initial lines 1 thru 5, and the remaining as needed.

EXAMINATIONS AND X-RAYS
I understand that the initial visit may require radiographs in order to complete the examination, diagnosis and treatment plan. I understand I am to have work done as detailed in the treatment plan. 

DRUGS AND MEDICATION

I have been informed and understand that antibiotics, analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). I have informed the Dentist of any known allergies. They may cause drowsiness, lack of awareness and coordination which can be increased by the use of alcohol or other drugs. I understand and fully agree not to operate any vehicle or hazardous device for at least 12 hours or until fully recovered from the effects of the anesthetic, medication and drugs that may have been given in the office for my care. I understand that failure to take medications prescribed for me in the manner prescribed may offer risks of continued or aggravated infection, pain and potential resistance to effective treatment of my condition. I understand that antibiotics can reduce the effectiveness of oral contraceptives (birth control pills). I understand that all medications have the potential for accompanying risks, side effects and drug interactions. Therefore, it is critical that I tell my dentist of all medications I am currently taking.

CHANGES IN TREATMENT PLAN

I understand that during treatment it may be necessary to change or add procedures because of the 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 the Dentist to make any/all changes and additions as necessary.

TEMPOROMANDIBULAR JOINT DYSFUNCTION (TMD)

I understand that popping, clicking, locking and pain can intensify or develop in the joint of the lower jaw (near the ear) subsequent to routine dental treatment wherein the mouth is held in the open position. Although symptoms of TMD associated with dental treatment are usually transitory in nature and well tolerated by most patients, I understand that should the need for treatment arise, then I will be referred to a specialist for treatment, the cost of which is my responsibility.

DENTAL PROPHYLAXIS

I understand the treatment is preventative in nature, intended for patients with healthy gums, and is limited to the removal of plaque and calculus from the tooth structures in the absence of periodontal (gum) disease.

PERIODONTAL TREATMENT

I understand that I have a serious condition causing gum inflammation and/or bone loss, and that it can lead to the loss of my teeth and/or negative systemic conditions (including uncontrolled diabetes, heart disease, and pre-term labor, etc). Alternative treatment plans have been explained to me, including non-surgical therapy, antimicrobial treatment, gum surgery and/or extractions. I understand the success of any treatment depends in part on my efforts to brush and floss daily, receive regular therapeutic cleanings as directed, follow a healthy diet, avoid tobacco products and follow other recommendations. I understand bleeding could last for several hours. Should it persist, particularly if it is sever in nature, it should received attention and this office must be contacted. I understand that periodontal disease may have a future adverse effect on the long-term success of dental restoration work.

FILLINGS

I understand that a more extensive restoration than originally diagnosed may be required due to additional decay or unsupported tooth structure found during preparation. This may lead to other measures necessary to restore the tooth to normal function. This may include root canal, crown or both. I understand that care must be exercised in chewing on fillings during the first 24 hours to avoid breakage. I understand that sensitivity is a common after effect of newly placed fillings.

CROWNS, BRIDGES, VENEERS AND BONDING

I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the permanent crowns are cemented. I realize that the final opportunity to make changes in my new crown, bridge, or veneer (including shape, fit size and color) will be before cementation. It has been explained to me that in few cases, routine and cosmetic procedures may result in the need for future root canal treatment, which cannot always be predicted or anticipated. I understand that cosmetic procedures may affect tooth surfaces and may require modification of daily cleaning procedures. If a restoration other than a “same day crown or bridge” it is my responsibility to return for permanent cementation within 20 days after tooth preparation. Excessive delays may allow for decay, tooth movement, gum disease, and/or bite problems. This may necessitate a remake of the crown, bridge, or veneer. I understand there will be additional charges for remakes or other treatment due to my delaying permanent cementation.

BRIDGE OR IMPLANT PLACEMENT

I am electing to do a fixed bridge or implant replacement of missing teeth instead of a removable appliance. I understand that this fixed bridge or implant crown may not be a covered benefit under an insurance policy.

DENTURES-COMPLETE OR PARTIAL

I realize that full or partial dentures are artificial, constructed of plastic, metal, and/or porcelain. The problems of wearing those appliance have been explained to me including looseness, soreness, and possible breakage. I realize the final opportunity to make changed in my new denture (including shape, fit, size, placement, and color) will be the “teeth in wax” try in visit. Immediate dentures (placement of dentures immediately after extractions) may be uncomfortable at first. Immediate dentures may require several adjustments and relines. A permanent reline or a second set of dentures will be necessary later. This is not included in the initial denture fee. I understand that most dentures require relining approximately three to twelve months after initial placement. The cost for this procedure is not included in the initial denture fee. I understand that it is my responsibility to return for delivery of dentures. I understand that failure to keep delivery appointments may result in poorly fitted dentures. If a remake is required due to my delay of more than 30 days, there will be additional charges.

ENDODONTIC TREATMENT (ROOT CANAL)

I realize there is no guarantee that root canal treatment will save my tooth, that complications can occur from the treatment and that occasionally, canal material may extend through the root tip which does not necessarily affect the success of the treatment. The tooth may be sensitive during treatment and even remain tender for a time after treatment. Hard to detect root fracture is one of the main reasons root canals fail. Since teeth with root canals are more brittle than other teeth, a crown is necessary to strengthen and preserve the tooth. I understand that endodontic files and reamers are very fine instruments and stresses can cause them to separate during use. I understand that occasionally additional surgical procedures may be necessary following root canal treatment (Apicoectomy). I understand that the tooth may be lost despite all efforts to save it.

NITROUS OXIDE

I elect to have nitrous oxide in conjunction with my dental treatment. I have been informed and understand the possible side effects that may occur. These include, but are not limited to, nausea, vomiting, dizziness and headache. I understand that nitrous oxide use is not indicated if I am pregnant.

DENTAL BENEFITS

It is very important that you read your insurance policy. Our office bills insurance as a courtesy and makes no guarantees of coverage. We do not allow insurance to influence our treatment plans. We will assist you in maximizing your benefits however our treatment plans are based on dental necessity. Some common non covered procedures, but not limited to are tooth colored fillings on back teeth (we no longer place amalgam fillings due to the high content of mercury), fluoride varnish, sealants over the age of 14, specific unique procedures requiring additional laboratory costs. Examples are same day EMAX or same day crowns, splints, all porcelain crowns, Valplast partial dentures, implant procedures, occlusal (night)
guards.

I understand that my insurance may provide only the minimum standard of care. I understand that submitting insurance and receiving a benefit the dental office will apply any insurance benefit to the treatment plan and I am responsible for any unpaid amount by the insurance carrier.

I understand that dentistry is not an exact science and that therefore reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the dental treatment I have requested and authorized.

The following ¡s a sample of the Dental Board of California Dental Materials Fact Sheet. The Depa-frnenf of Consumer Affairs has no position with respect to the language of this document and it’s linkage to the DCA web site does not constitute an endorsement of the content of this document.

The Dental Board of California
Dental Materials Fact Sheet
Adopted on 10/17/01

As required by Chapter 801, Statutes of 1992, the Dental Board of California has prepared this fact sheet to summarize information on the most frequently used restorative dental materials. Information on this fact sheet ¡s intended to encourage discussion between the patient and dentist regarding the selection of dental materials best suited forme patient’s dental needs. IT is not intended to be a complete guided to dentol materials science.

The most frequently used materials in restorative dentistry are amalgam, composite resin, glass ionomer cement, resin ionomer cement, ceramic porcelain, and porcelain fused to metal, gold alloys (noble) and nicket or cobalt-chrome (base metal) alloys. Each material has its own advantages and disadvantages, benefits and risks. These and other relevant factors and compared in the attached matrix titled “Comparisons of Restorative Dental Materials.” A glossary of terms is also  attached to assist the reader in understanding the terms used.

The statements made are supported by relevant, credible dental research published mainly between 1993 and 2001. In some cases, where contemporary research is spare, we have indicated our best perceptions based upon information that pre-dates 1993.

The reader should be aware that the outcome of dental treatment or durability of a restoration is not solely a function of the material from which the restoration was made. The durability of any restoration is influenced by the dentist’s technique when placing the restoration, the ancillary Materials used in the procedure and the patient’s co-operation during the procedure. Following restoration of the teeth, the longevity of the work will be strongly influenced by the patient’s compliance.

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or
healthcare operations.

By signing this form, you consent to our use and disclosure of your protected heslthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be reoactive.

By signing this form, I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information but the practice does not have to agree to those  restrictions.
• The patient has the right to revoke this consent in iting ax any time and all full disclosures will then cease.
• The practice may condition receipt of treatment upon execution of this consent.

Appointment Cancellation and No-Show Policy Truly Yours Family Dental is privileged to provide dental treatment to our patients. We will work diligently to maintain a high level of personalized service and will strive to accommodate our patients’ need for office visits in a timely manner. This requires careful planning and coordination among many individuals in our office.

We understand that emergencies arise from time to time. just as they do for us; however, when a patient fails an appointment or cancels without adequate notice. we cannot use that time to meet the needs of other patients. We respectfully request your understanding and agreement to our policy as it is stated below.

Our office will charge a fee of $75.00 to your account for all "no-shows” or cancellations in which the patient does not give our office at least 48 hours notice. The office requests that if you are unable to make your scheduled appointment, you call to re-schedule your appointment. We will give you a reminder phone call within at least 48 hours of your scheduled appointment. For Monday appointments, cancellations must be made by noon on the preceding Friday.
Cancellations may not be called into our answering service.

The scheduling parent or scheduling legal guardian of minors who fail or cancel appointments with less than 48 hours’ notice will be held responsible for the missed appointments. Fees charged by Truly Yours Family Dental pursuant to this policy are not payable by insurance companies. All fees must be paid prior to your scheduling another appointment or within 30 days of a billing statement, whichever is earlier.

We thank you for your understanding and your commitment. Our office is committed to providing the highest quality dental care to all of our patients. We thank you for choosing Truly Yours Family Dental to serve your oral Health which leads to overall health and well-being.