Patient Information Form Step 1 of 11 9% HiddenPatient InformationYour Name(Required) First Middle Last Soc. Sec. # Address Street Address City State / Province / Region ZIP / Postal Code Home PhoneCell PhoneEmail Gender M F Age Birth date MM slash DD slash YYYY Status Single Married Widowed Separated Patient Employed by Occupation Business Address Business Email Business PhoneWhom may we thank for referring you? Emergency ContactBusiness PhoneHome PhoneCell PhoneEmail Dental InsuranceWho is responsible for this account? Relationship to patient Insurance Co. Group # Is patient covered by additional insurance? Yes No Member ID # Subscriber's name BirthdayMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY202720262025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SS # Relationship to patient Insurance Co. Group # Name of Insurance Company(Required) ASSIGNMENT AND RELEASE I certify that l, and/or my dependent(s), have insurance coverage with (Above Entered Insurance Company) and assign directly to the Doctor(s) of Highpoint Dental Care all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether paid by insurance. I authorize the use of my signature on all insurance submissions. The above-named dentist may use my health care information and may disclose such information to the above-named Insurance Company and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services.HiddenSignature of patient, parent, guardian or personal representative Signature of patient, parent, guardian or personal representative Clear Signature Field 1 Please print name of patient, parent, guardian or personal representative Date MM slash DD slash YYYY Relationship to patient Dental HistoryWhat is your main dental concern today? Are you experiencing any dental pain? Select your level of dental anxiety on a scale of 1 to 10:1 (Lowest)2345678910 (Highest)Select your level of daily hygiene on a scale of 1 to 10:1 (Poor)2345678910 (Exceptional)Select the level of satisfaction with your teeth/smile:1 (I want a new smile)2345678910 (I wouldn't change a thing)Former Dentist State City Date of last dental visit MM slash DD slash YYYY Date of last X-rays MM slash DD slash YYYY Please check if you have any of the following: Adverse reaction to dental work Bad breath Bleeding gums Cigarette or Nicotine Products Clicking or popping jaw Dry Mouth Food collection between teeth Grinding or clenching teeth Gum disease treatment Loose teeth or broken fillings Orthodontic treatment (braces) Sensitive teeth Sleep Apnea TMJ/jaw pain Vaping or recreational marijuana Yellow/dark teeth How often do you brush? How often do you floss? Hidden Medical HistoryPhysician's Office Physician's Name Phone City Date of Last Visit MM slash DD slash YYYY Do you have any systemic conditions or serious illnesses? Yes No Describe Are you currently under physician care? Yes No Describe Have you ever had a blood transfusion? Yes No Give approximate date(s) Have you ever taken weight reduction medications such as Fen-Phen/Redux? Yes No Have you ever taken medications to treat osteoporosis such as Bisphosphonates? Yes No Have you had major surgeries? If yes, list them:Women: Are you pregnant? Yes No Nursing? Yes No Taking birth control pills? Yes No Have you been infected with COVID-19? Yes No Have you received a COVID-19 vaccination? Yes No Please check if you have any of the following: AIDS/HIV Positive Anaphylaxis (Severe Allergy) Anemia Arthritis, Rheumatism Artificial heart valves Artificial joints Asthma Back problems Blood disease Cancer Chemical dependency Chemotherapy Circulatory problems Cortisone treatments Cough, persistent Diabetes Epilepsy Fainting Fibromyalgia Fungus/infection Gastric reflux Genetic disorder Glaucoma Headaches Heart murmur Heart problems Hemophilia/Abnormal bleeding Herpes Hepatitis High blood pressure Jaw pain Kidney disease or malfunction Liver disease Mitral valve prolapse Nervous problems Pacemaker/Heart surgery Psychiatric care Rapid weight gain or loss Radiation treatment Respiratory disease Rheumatic fever Scarlet fever Shingles Shortness of breath Skin rash Stroke Surgical implant Swelling of feet or ankles Thyroid disease or malfunction Tobacco habit Tonsillitis Tuberculosis Tumors/growths Ulcer/Colitis Venereal disease Describe Heart problems Are you allergic to any of the items below: Aspirin Barbiturates (Sleeping pills) Codeine Iodine Latex Local Anesthetic Penicillin Sulfa Others Others List medications you are currently taking, if any: Updates (future appointments only)Has there been any change in your health since your last dental appointment? Yes No For what conditions? Are you taking any new medications? Yes No Which medications? HiddenPatient's signature Date MM slash DD slash YYYY Patient's signature Clear Signature Field 2 HiddenProvider's signature Date MM slash DD slash YYYY Provider's signature Clear Signature Field 3 Has there been any change in your health since your last dental appointment? Yes No For what conditions? Are you taking any new medications? Yes No Which medications? HiddenPatient's signature2 Date MM slash DD slash YYYY Patient's signature Clear Signature Field 2 HiddenProvider's signature Date MM slash DD slash YYYY Provider's signature Clear Signature Field 3 Has there been any change in your health since your last dental appointment? Yes No For what conditions? Are you taking any new medications? Yes No Which medications? HiddenPatient's signature3 Date MM slash DD slash YYYY Patient's signature Clear HiddenSignature Field 3 HiddenProvider's signature3 Date MM slash DD slash YYYY Provider's signature Clear Patient Appointment and Cancellation Policy Dear Valued Patient, Our purpose is to help every patient who walks through our doors achieve optimal dental health in a timely manner. Once you have booked your appointment with our office it means we have reserved time exclusively for you, and that time cannot be used to treat another patient. We understand that sometimes rescheduling and cancellations may be necessary; however, we require at least a 24 hour notice for these changes. Some appointments may require a deposit to reserve a specific time or amount of time, and fees may be deducted from this deposit for failure to follow this policy. Any established patient who fails to show or cancels/reschedules an appointment less than 24 hours before it is scheduled to take place, will be subject to a cancellation fee of $50 due in-full prior to your next appointment. This fee is not reimbursable by your insurance company and you will be billed to you directly. Any established patient who fails to show or cancels/reschedules an appointment without a 24 hour notice a second time will be charged a $100 fee and will be required to pay for the next appointment in advance. Any established patient who fails to show or cancels/reschedules an appointment without a 24 hour notice a third time will be charged a $150 fee, be required to pay for all appointments in advance, and may be dismissed from the practice. Please understand that it is your responsibility to remember your appointment dates and times in order to prevent any missed appointments which result in a cancellation fee. As a courtesy we do provide reminders for all appointments beginning 2 weeks prior. To avoid cancellation fees and potential dismissal, please provide cancellation notice at least 24 hours prior to your appointment. Your appointment should only be cancelled or rescheduled by CALLING the office during business hours. Text and/or email DOES NOT serve as a method to cancel unless it is acknowledged prior to the 24 hour policy. Keep in mind an appointment scheduled on a Monday for the following week will need to be cancelled prior to the weeks closing hours to meet the proper 24 hour cancellation as we are not open on Saturday and Sunday. Should you have any questions about our policy, please don’t hesitate to ask. We are here to serve our patients and believe that good communication is key to excellence in dental care. HiddenPatient Signature: Date MM slash DD slash YYYY Patient Signature: Clear Signature Field 8 Payment ConsentAll estimated co-pays are expected at the time of service. We wish to prevent any misunderstandings about payment for professional services, therefore please be aware you are responsible for all fees. Insurance is a contract between you and a third party to reimburse for covered dental benefits. We cannot guarantee insurance company payments for specific procedures, eligibility, deductibles, restrictions, or utilization requirements. Insurance is not a substitute for payment and it is truly YOUR responsibility to understand your own benefit plan. If you subscribe to a DMO, HMO, government, or an EPO plan, you may have reduced benefits or no coverage in this office. Seeing as how we accept and submit to most all insurance plans, you are ultimately responsible for knowing whether you are in-network or out-of-network with our office. If you would like a written preauthorization for dental treatment, it is your responsibility to request this prior to the actual appointment, however, even this cannot guarantee coverage following a procedure. We will always advocate for you as your dental provider to your third party insurance provider.After my dental insurance company has paid its portion of the dental services rendered at the office of Highpoint Dental Care, I, Name hereby give my consent to this office to charge any outstanding balance to my account. This balance may include deductible, denied procedures as well as non-covered services, and will be charged to my account after a period of 60 days from the time of treatment or upon receipt of the insurance, whichever comes first. You will receive an EOB (explanation of benefits) before we receive payment. If you have any concerns about your portion, please call. Any request for complimentary initial scans or radiographs that were taken will be honored but will require payment in full prior to release.Name (Print): HiddenSignature: Date: MM slash DD slash YYYY Signature: Clear Signature Field 9 Acknowledgment of Insurance Billing LimitationsI understand that dental insurance plans vary widely in what services, procedures, and codes they consider billable or covered. I acknowledge that certain dental procedures, materials, or treatment codes provided by Highpoint Dental Care and Implant Center may be considered: Non-billable to my insurance plan, or Not covered benefits under my policy, or Services for which my insurance will deny payment, even if treatment is necessary Additional, unforeseen procedures or supplemental items that must be added during treatment These services may still be recommended and presented as part of my necessary dental care. Patient Agreement to Pay for Non-Billable ServicesI understand and agree that if a procedure or dental code is determined to be non-billable or not reimbursable by my insurance company, I am personally responsible for payment of all associated charges. This includes, but is not limited to: Upgraded materials, medication, dental supplies, or alternative treatment options Services not recognized by my insurance carrier Procedures deemed elective or outside plan coverage Codes insurance considers “non-covered” or “patient responsibility Digital services and developed processes that do not have dental coding available to be billed to insurance Cancellation fees or requested records fees Payment ResponsibilityI agree to pay for any non-billable or non-covered services at the time of treatment unless other arrangements have been made in writing. I understand that Highpoint Dental Care and Implant Center may provide an estimate of benefits; however: Insurance estimates are not guarantees of payment Final determination of coverage is made solely by my insurance carrier Any unpaid balance remains my responsibility AuthorizationBy signing below, I confirm that I have read and understand this waiver. I agree to be financially responsible for charges related to services that are non-billable or not covered by my dental insurance plan. Printed Name: Date: MM slash DD slash YYYY Signature: Clear Special Note to Patients A professional cleaning is a medical procedure prescribed by a qualified health care practitioner (dentist or dental hygienist). Legally and ethically, a diagnosis must be made to prescribe a cleaning procedure. As there are several types or required cleanings to address various types of gum disease, an examination and radiographs are required by the dental practitioner initially and periodically throughout one’s treatment. After the exam and radiographs have been completed, the doctor will determine the order and importance of treatment. In some cases, existing dental conditions may have to be addressed before cleaning one’s teeth. In these circumstances, other types of treatment may be required first to provide for the health of the patient. Highpoint Dental Care is committed to helping our patients achieve their goals, needs, and desires for their dental health. Using diagnosis to recommended procedures is consistent with the American Dental Association and current clinical research. This practice policy is also in the interest of maintaining the longevity of natural teeth, implants, and prosthetics created at our office and elsewhere. NOTICE OF PRIVACY PRACTICESTHIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US. OUR LEGAL DUTY We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice is effective March 19, 2026, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you. 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 our healthcare operations. Your Authorization: You may give us written authorization to use or disclose your information and may revoke it at any time. To Your Family and Friends: We may disclose information to individuals involved in your care if you agree. Persons Involved in Care: We may notify individuals responsible for your care. Marketing: We will not use any health information for marketing without authorization. Photography and Media Use: We may take and use photographs, images, or recordings of you that do not identify you for purposes including education, documentation, marketing, social media, and other practice-related uses. By receiving services from our practice and acknowledging this Notice, you consent to such use and disclosure, provided that no identifying information is included. Required by Law: We may disclose your health information when required by law. Abuse or Neglect: We may disclose your health information to appropriate authorities if necessary. National Security: We may disclose information under lawful circumstances. Appointment Reminders: We may use your information to send reminders. CONFIDENTIALITY OF SUBSTANCE USE DISORDER (SUD) RECORDS Certain health information related to Substance Use Disorder (SUD) diagnosis, treatment, or referral for treatment is protected by federal law and regulations under 42 CFR Part 2. We will not use or disclose SUD records without your prior written consent unless permitted or required by 42 CFR Part 2. Any disclosure made with your written consent will include a statement prohibiting redisclosure. Federal law permits disclosure without consent only in limited circumstances. Violations of 42 CFR Part 2 may be reported to the United States Attorney. PATIENT RIGHTS Access: You have the right to inspect or obtain copies of your health information, with limited exceptions. Requests must be made in writing and charges will comply with Colorado law. Disclosure Accounting: You may request a list of disclosures for the past six years (not before April 14, 2003). Restriction: You may request restrictions; we are not required to agree. Alternative Communication: You may request amendments in writing. Electronic Notice: You may request a written copy of this Notice. CONTACT INFORMATION Highpoint Dental Care and Implant Center 3574 S. Tower Rd Unit B Aurora, CO 80013 Phone: (303) 617-9100 Fax: (303) 617-9198 Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.I have read the above statement, understand it, and have been given the opportunity to ask any questions about it.(Required) I have read the above statement, understand it, and have been given the opportunity to ask any questions about it.(Required)Name (Print): HiddenSigned: Date: MM slash DD slash YYYY Signed: Clear Signature Field 10 I agree to terms & conditions provided by Highpoint Dental. By providing my phone number, I agree to receive text messages from Highpoint Dental.(Required) I agree to terms & conditions provided by Highpoint Dental. By providing my phone number, I agree to receive text messages from Highpoint Dental.(Required)ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESConsent(Required) I have received a copy of this office's Privacy Practices.(Required)Name (Print):(Required) HiddenSigned:(Required) Date:(Required) MM slash DD slash YYYY Signed: Clear Signature Field 11
