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elcome to Valley Dental Associates!
Please complete all parts for our records. This information is strictly kept confidential.
GETTING TO KNOW YOU
CITY STATE SINGLE MARRIED DIVORCED OTHER OTHER PEOPLE YOU KNOW WHO ARE PATIENTS HERE NAME AND PHONE NUMBER OF EMERGENCY CONTACT IS THERE ANYTHING YOU WOULD LIKE US TO KNOW THAT WOULD HELP US TREAT YOU MORE REASON FOR LEAVING PREVIOUS DENTIST ACCOUNT INFORMATION
PERSON FINANCIALLY RESPONSIBLE FOR ACCOUNT
PATIENT HEALTH HISTORY
1. When was your last Dental Examination and Cleaning? __________ 2. Have you been a patient in the hospital during the past two (2) years?.Y/N If yes, please explain ______________________________________________________ 3 Have you been under the care of a medical doctor during the past two (2) years?.Y/N If yes, please explain______________________________________________________ Physician’s Name____________________________ Phone Number ____-____-______ 4. Have you taken any medicine or drugs in the last two (2) years?.Y/N 5. Are you now taking any prescribed or non-prescription medication, drugs, or pills?.Y/N If yes, please list__________________________________________________________ ________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________ 6. Are you allergic or have you reacted adversely to any of the following medications? (please circle YES or NO) Aspirin Y/N Erythromycin Y/N Scopolamine Y/N Novocain 7. Are you aware of being allergic to any other medications, food, or substances?.Y/N If yes, please list________________________________________________________________ ________________________________________________________________________________ 8. Have you ever had or do you have at present: Y/N Cortisone Medicine Y/N Psych. Treatment 9. When you walk up stairs, do you ever have to stop because of pain in your chest or shortness of breath?.Y/N 10. Do your ankles swell during the day?.Y/N 11. Do you use more than two (2) pillows to sleep?.Y/N 12. Have you lost/gained more than 10 pounds in the last year?.Y/N 13. Do you ever wake up from sleep short of breath?.Y/N 14. Are you on a special diet?. .Y/N 15. Has your medical doctor ever said you have cancer or a tumor?.Y/N 16. Do you have any disease, conditions or problems not listed?.Y/N If yes, please explain______________________________________________________________ ___________________________________________________________________________________ 17. Do you smoke?.Y/N 18. Do you participate in any activity that would increase the possibility of HIV infection?.Y/N 19. Have you ever had an HIV blood test?.Y/N Date__________________________________ 20. Have you ever experienced a sensitivity to latex?.Y/N
21. Have you taken or are you taking Biphosphonates (Aridia, Fosamax, Actonel, Actonel, etc.)……Y/N 22. Have you ever taken Fen-Phen or Redux?.Y/N 23. Is there any other medical information you would like us to know?.Y/N If yes, please explain ____________________________________________________________________ _________________________________________________________________________________________
FOR WOMEN ONLY
Are you pregnant?.Y/N
If yes, what week?___________________________________________________________________ If yes, what is the name of the prescription?_______________________________________________ The undersigned hereby authorizes Doctor, after consultation with patient (or parent, if minor) to take X-rays, study modules, photographs, or any other diagnostic aids deemed appropriated by the Doctor to make a thorough diagnosis of the patient’s dental needs. I also authorize the Doctor to perform any and all forms of treatment, medication, and therapies that may be indicated and further authorize and consent that the Doctor choose and employ such assistance as he deems fit. I also under the use of anesthetic agents carry a certain risk. I certify the above information is true and correction: Authorization for Release of Protected Health Information to a Specified Spokesperson
As stated in the Valley Dental Associate’s (VDA) Notice of Privacy Practices, “We may release health
information about you to a family member, other relative, or any other person identified by you who is
involved in your care with your permission.”
By signing this authorization, I allow VDA to tell the spokesperson(s) named below to
the following information:
My x-rays, laboratory, test findings, diagnosis, prognosis, and treatment plan either in person or by telephone.
By signing this authorization, I understand the following.
This applies to services being rendered to me by Valley Dental Associates. This authorization is voluntary. Once this information is released to the spokesperson(s), the released information may no longer be protected by the federal privacy regulations. The spokesperson(s), medical power of attorney, health care agent or other individual allowed by law will be the only person(s) who may obtain specific information about me. My spokesperson(s) does not have decision-making abilities unless he/she is able to do I may withdraw this authorization at any time by notifying the Valley Dental Associates Privacy Officer in writing. If I do withdraw the authorization, it will not have any effect on actions taken by VDA prior to receiving the written request. My treatment will not be affected by me choosing to sign or not to sign this document. I may refuse to sign this authorization You may receive a copy of this form once it is completed
Print Patient’s Name___________________________________________DOB_____________
Name __________________________ Relationship_______________ Phone_______________ Name __________________________ Relationship_______________ Phone_______________ Name __________________________ Relationship_______________ Phone_______________ Name __________________________ Relationship_______________ Phone_______________ Patient’s Signature _____________________________________________ Date____________ FINANCIAL POLICY
Thank you for selecting us as your dental health care provider. My staff and I are committed to your treatment being a positive experience Please understand your financial obligations are considered part of your treatment. The following is a statement of our financial policy. Please read and sign before being seen by Dr. Winebrenner and his associates. 1. All patients are required to complete our Patient History and all Insurance forms before seeing the doctor. Payment options include: Cash, Checks, and Credit Cards Extended payment plan (with prior credit approval) through CARE CREDIT 2. Patients with dental insurance are required to pay their deductible and portion of our fees at the time treatment is
rendered. As a courtesy to you, we will accept assignment of insurance benefits. However, we do required total bills
plus any deductible to be paid at time of service, based on insurance co-payment. A refund check will be mailed to you
if an insurance carrier pays more than the estimated amount.
3. A few of our patients have the misconception that we know all the details about their insurance. Since the early 80’s
dental insurance guidelines have become more and more complicated to understand and control. Please understand
filing insurance is a courtesy we extend to our patients, we must emphasize that as dental providers, our relationship is
with our patients, not the insurance company. The insurance information we receive is limited to what is covered –
not what is not covered. Your insurance is a contract between your employer and the insurance company. We
sincerely encourage you to contact your insurance company to obtain a list of procedures and limitations not
covered. Especially since any dental procedure that is not covered or has not been paid in full by your insurance
carrier within 60 days, is your responsibility. This is important for you to know. This unpaid balance will be subject
to a finance charge of 1½% per month, plus a monthly billing fee for $5.00 if not pain within the next thirty (30) day
Usual and Customary Rates
Our practice is committed to providing the best treatment for our patients, and we charge what is usual and customary for our area. You are responsible for payment regardless of any insurance company’s arbitrary determination of usual and customary rates. Minor Patients
The adult accompanying a minor is responsible for full payment the day treatment is rendered. Missed Appointments
Your scheduled appointment time has been reserved at your request. If this time becomes inconvenient for you, please notify our office within 48 hours before that scheduled time or a fee will be charged. It is not our intention to charge you; however we do required this notification to offer this time to another patient. Please help us avoid charging a fee by keeping your scheduled appointment. Print Name______________________________Signature__________________________Date_________________
Please complete this evaluation so we know how to help you achieve the smile that will make you
1. Are you 100% happy with the appearance of your teeth and your smile?
If no, what would you like to change, if possible? ____ spaces between my teeth ____ uneven teeth ____ chipped teeth ____ amount of gum tissue that shows when I smile ____ crooked or overlapping teeth that show when I smile ____ visibly missing teeth ____ visible metal restorations ____ old crowns, bridges, or dentures ____ other – please explain in detail_______________________________________________________ _____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ 2. Are any of your teeth loose or causing you discomfort? If yes, please explain in detail_________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________ 3. Do you have any questions about dentistry or your oral health that have never been adequately If yes, please explain in detail_________________________________________________________ _____________________________________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________ 4. Is there anything you would like the Doctor or Hygienist to discuss with you today? YES NO If yes, please explain in detail_________________________________________________________ __________________________________________________________________________________________________________________________________________________________________________ _____________________________________________________________________________________ 5. Would you like one of our Business Assistants to discuss dental financings programs available Valley Dental Associates
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF
*You may refuse to sign this acknowledgement*
I, _________________________________, have read and received a copy of this office’s
Notice of Privacy practices.
Please Print Name
We may use or disclose your health information to a physician or other health care operations. We may use or disclose your health
information to a physician or healthcare provider providing treatment to you. We may use and disclose your health information to
obtain payment to services we provide for you (insurance companies). We may use and disclose your health information in connection
with our healthcare operations. These include quality assessment and improvement activities, reviewing the competence or
qualifications of healthcare professions, evaluating practitioner and provider performance, conducting training programs,
accreditation, certification, licensing or credentialing activities. You may also give us written authorization to use your health
information or to disclose it to anyone for any purpose. If you give us authorization, you may revoke it in writing at any time.
However, your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. We must
disclose your health information to you. We may disclose your health information to a family member, friend or other person to the
extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. We may
use or disclose health information to notify or assist in the notification of a family member, your personal representative or another
person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure
of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your
incapability or emergency circumstances, we will disclose health information based on a determination using our professional
judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use
our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing
a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information. We will NOT use your
health information for marketing communications without your written authorization. We may use or disclose your health
information when we are required to do so by law. We may disclose your health information to appropriate authorities if we
reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We
may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety
of others. We may disclose to military authorities the health information of Armed Forces Personnel under certain circumstances.
We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other
national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of
protected health information of inmate or patient under certain circumstances. We may use or disclose your health information to
provide you with appointment reminders (phone calls, e-mails, post cards). You have the right to get copies of your health
information, with limited exceptions. You have the right to receive a list of instances in which we or our business associates
disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for
the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge
you a reasonable, cost-based fee for responding to these additional requests. You have the right to request that we place additional
restrictions on our use of disclosure of your health information. We are not required to agree to these additional restrictions, but if
we do, we will abide by our agreement, except in the case of an emergency. IF YOU RECEIVE THIS NOTICE ON OUR WEBSITE
OR BY ELECTRONIC FORM, YOU ARE ENTITLED TO RECEIVE THIS NOTICE IN WRITTEN FORM, UPON REQUEST.
Email Delivery Are my emails reaching the intended audience? If you send regular emails to your customers and/or prospects the bad news is that not all of your emails are making it to your intended recipients, even if you have accurate email addresses. Chances are that ISP SPAM filter software, SPAM-blocking email servers, and email content filters are roadblocks to your emails.