New Patient Form – krystalsmiles

Patient Information

Name *

Gender *MaleFemale

SSN *

Date of Birth *

Street Address *

City *

State *

ZIP *

Phone No. Home

Cell *

Work *

Email Address *

May we contact you by email? *YesNo

Emergency Contact

Phone *

Dental Insurance Information

Relationship *

Employer Name *

Employer Phone *

Insurance Company *

Insurance Phone *

Insurance ID No *

Insurance Group No *

Do you have an additional insurance? *YesNo

Subscriber Name *

Relationship *

Employer Name *

Employer Phone *

Insurance Company *

Insurance Phone *

Insurance ID No *

Insurance Group No *

Medical HistoryAlthough dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Please answer the following medical history questions as correctly as possible.

Are you currently under the care of a physician? *YesNo

Physician Name

Phone

Authorization

I authorize the disclosure of information from my treatment records to:

Name of Recipient *

Relationship *

I give authorization to disclose the following information:

All treatment informationSpecific Date

I understand that I may withdraw or revoke my permission at any time with written words.

Printed name & Signature of Patient/Parent/Guardian *

Date *

INFORMED CONSENT

Dental Examination and Treatment Plan *California Law requires that the dentist examine and diagnose all new prior to delegating general supervision duties to auxiliaries including hygienist for cleaning.

Changes in Treatment Plan *I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination. For example, root canal therapy may follow routine restorative procedures. I give my permission to the Dentist to make any and all changes and additions as necessary, after explaining the reason and obtaining my consent.

Drug and Medications *I understand that antibiotics, analgesics and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and or anaphylactic shock.

Periodontal Loss *I understand that periodontal disease is a condition of the gums and bone and it can lead to eventual tooth loss. Alternative treatment plans have been explained to me, including scaling, root planning, medicinal irrigation, and gum surgery replacement and/ or extraction. I understand that undertaking any dental procedures may not prevent continued bone loss. I understand that I may require constant maintenance.

Fillings *I understand that care must be exercised in chewing on new fillings especially during the first 24 hours, to avoid breakage. I understand that a more extensive filling than originally diagnosed may be required due to additional decay. I understand that significant sensitivity is a common after effect of a newly placed filling.

Crowns, Bridges and Caps *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 delivered. I realize the final opportunity to make changes in my new crown, bridge, or cap (including shape, fit, size and color) will be before cementation. It is also my responsibility to return for permanent cementation within 30 days from tooth preparation. Excessive delays may allow for tooth movement. This may necessitate a remake of the crown, bridge, or cap. I understand there will be additional charges for remakes due to my delaying permanent cementation. Endodontic (root canal) may be necessary after or during crown cementation.

Endodontic Treatment (Root Canal) *I realize there is no guarantee that root canal treatment will save my tooth, and that complication can occur from the treatment and 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. In some cases, a preciously treated tooth should be restored as soon as possible to protect it from fracture or decay.

Removal of Teeth *Alternative to removal have been explained to me (root canal therapy, crown and periodontal surgery, etc.). I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risks involved in having teeth removed, some of which are pain, swelling, and spread of infection, dry socket, loss of feeling in my teeth, lips tongue and surrounding tissue (paresthesia) that can last for an indefinite period of time or fractured jaw. I understand I may result in poorly fitting dentures. If a remake is required due to my delays of more than 30 days, there will be additional, charges.

Dentures *I understand the wearing of dentures is difficult. Sore spots, altered speech, and difficulty in eating are common problems. Immediate dentures (placement of denture immediately after extractions) may be painful. Immediate dentures may require considerable adjustment and several relines. A permanent reline will be need later. This is not included in the original denture fee. I understand that it is my responsibility to return for delivery of the dentures. I understand that failure to keep my delivery appointment may result in poorly fitting dentures. If a remake is required due to my delays of more than 30 days, there will be additional charges.

Cosmetic services *Cosmetic services may not be covered by insurance plans. This includes porcelain facings on molars, cosmetics bleaching, cosmetic bonding and laminated (veneers).

Optional Treatment (Bone Graft & Sinus Lift) *The need for treatment that is excluded as a benefit by insurance has been explained to me. If I choose to proceed, the use and cost of noble metals, including gold, will be with my consent.

I hereby authorize any of the doctors to proceed with and perform the dental restorations and treatments explained to me. I understand that regardless of any dental insurance coverage I may have, I am responsible for payment of dental fees. Should any dispute arise over dental services provided to me, which is whether any dental service rendered was allegedly necessary, unauthorized or was improperly, negligently, or incompetently performed said dispute will be submitted to peer review by an appropriate dental society, which will be a component of the American Dental Association. The decision of peer review shall be binding on both parties. I have read, understood and agreed to everything above numbers 1-11.

Signature *

Date *

NOTICE OF PRIVACY PRACTICESTHIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT TOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATIONS. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US

USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment and health care operations. For example:

Treatment: We may use of disclose your health Information to a physician or other healthcare provider providing treatment to you, or to family and friends you approve.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with your health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner, and provider performance, conducting training programs, accreditation, and certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment for healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. You also have the right to request restrictions on disclosure of PHI (Personal Health Information), or alternative means of communication to ensure privacy.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law or national security activities.

Abuse or Neglect: We may disclose your health information to appropriate authorities when we suspect abuse or neglect.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

Patient Rights

Access: You have the right to look at or get copies of your health information with limited exceptions. If you request copies, we will charge you a reasonable fee to locate and copy your information and postage if you want the copies mailed to you.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contract information listed at the end of this Notice. You also may submit a written complaint to the U.S. department of Health and Human Services. We will provide you with the address to file your complaint with the US Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us with the U.S. Department of Health and Human Services.

A Privacy/Contract Officer has been designated for this office. Please ask our front desk personnel and they will direct you to the Privacy/Contract Officer.

PATIENT ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT FOR NECESSARY USE OF PERSONAL HEALTH INFORMATION

Signature of Patient or Parent/Legal Guardian *

Date *

I, ____________________________________, have received a copy of this office’s NOTICE OF PRIVACY PRACTICES *

As required by federal law and I consent to the use and disclosure of my personal health information by your office during Treatment, Billing/Payment and Healthcare Operations as outlines in the Notice of Privacy Practices.

Witness Signature *

Date *

PATIENT CONSENT FORM

I understand that under the Health Insurance Portability & Accountability Act of 1996(HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to: • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in the treatment directly or indirectly • Obtain payment from a third-party payer. • Conduct normal healthcare operations such as quality assessments and physician certifications. I have been informed by Krystal Smiles Dental a more complete description of these uses and disclosures of my health information. I have been given the right to review the Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Volume of privacy practices from time to time and that I may contact this organization at any time at the address below to obtain a current copy of the Notice of Privacy Practices. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment. Payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.

Patient name *

Signature *

Relationship to patient *

Date *

Krystal Smiles Dental, 181 E 18th Street, Costa Mesa, Ca. 92627

Phone: (949) 822-3018

Fax: (949) 991-2225

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