Patient Information Form 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 BirthdayMM123456789101112DD12345678910111213141516171819202122232425262728293031YYYY2025202420232022202120202019201820172016201520142013201220112010200920082007200620052004200320022001200019991998199719961995199419931992199119901989198819871986198519841983198219811980197919781977197619751974197319721971197019691968196719661965196419631962196119601959195819571956195519541953195219511950194919481947194619451944194319421941194019391938193719361935193419331932193119301929192819271926192519241923192219211920SS # 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.Signature of patient, parent, guardian or personal representative 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? HiddenMedical 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:Updates1)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? Patient's signature Date MM slash DD slash YYYY Provider's signature Date MM slash DD slash YYYY 2)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? Patient's signature Date MM slash DD slash YYYY Provider's signature Date MM slash DD slash YYYY 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? Patient's signature Date MM slash DD slash YYYY Provider's signature Date MM slash DD slash YYYY Photography ConsentI, (Patient Name) agree to allow the dentists and staff of Highpoint Dental Care to take photographs or videos of my oral condition before, during, and after treatment performed. I consent to the photographs or videos to be used to help in achieving: 1. Proper diagnosis 2. Pre-consultation information 3. Dental record keeping (Accurate documentation) 4. Patient education 5. Communication with our laboratories 6. Marketing and research I further understand that if the photographs and/or videos are used, my name or identifying information will not be utilized and kept confidential. I will not expect compensation, financial or otherwise, for the use of any photographs or videos. HiddenI agree for the following: I, authorize Highpoint Dental Care, to take photographs, and/or videos of my face, jaws and teeth before, during, and after treatment. I consent to allow the photographs to be used for the following: • Dental Records • Dental Research • Dental Education including lectures, seminars, demonstrations, professional publications such as journals or books • Marketing material, including websites and printed materials, patient education I further understand that if the photographs and/or videos are used, my name or other identifying information will be kept confidential. I do not expect compensation, financial or otherwise, for the use of these photographs.Signature (Patient) Date MM slash DD slash YYYY Patient Appointment and Cancellation Policy Dear Valued Patient, Our purpose is to help every patient who walks through our doors achieve their dental goals in a timely manner. Once you have booked your appointment with us it means we have reserved time in our schedule 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 the below fees may be deducted from this deposit. 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 directly for it. 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 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 starting 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 weekend to meet the proper 24 hour cancellation as we are not open on Saturday and Sunday. Should you have any questions about our policy, we are here to serve our patients and believe that good communication is key to excellence in dental care.Patient Signature: Date MM slash DD slash YYYY Payment Consent All 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. InsuranceInsurance is a contract between you and a third party to reimburse for covered dental benefits. We cannot guarantee insurance company payments if you have not met eligibility, deductibles or utilization requirements. Insurance is not a substitute for payment and you must understand your own benefit plan. If you subscribe to a DMO, HMO, or an EPO plan, you may have reduced benefits or no coverage in this office. Seeing as how we accept and submit to 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. 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.Name (Print): Signature: Date: MM slash DD slash YYYY Special Note to Patients A professional cleaning is a medical procedure that must be 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. After the exam and radiographs have been completed, the doctor will determine the order 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 dental goals, needs, and desires. Using diagnosis to recommended procedures is in line with the American Dental Association and current clinical research. They are also in the interest to maintain the longevity of natural teeth, implants, and prosthetics. I have read the above statement, understand it, and have been given the opportunity to ask any questions about it. HiddenI have read the above statement, understand it, and have been given the opportunity to ask any questions about it. I have read the above statement, understand it, and have been given the opportunity to ask any questions about it.Name (Print): Signed: Date: MM slash DD slash YYYY ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICESConsent I have received a copy of this office's Privacy Practices.Name (Print): Signed: Date: MM slash DD slash YYYY For Office Use OnlyWe attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but acknowledgement could not be obtained because:• Individual refused to sign • Communications barriers prohibited obtaining the acknowledgement • An emergency situation prevented us from obtaining acknowledgement • Other (Please Specify)Presented By: Date MM slash DD slash YYYY 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 takes effect March 28, 2003, 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. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice. USES AND DISCLOSURES OF HEALTH INFORMATION We use and disclose health information about you for treatment, payment, and healthcare operations. For example: 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. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs. accreditation, certification, licensing, or credentialing activities. Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice. To Your Family and Friends: We must disclose your health information to you. as described in the Patient Rights section of this Notice. 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. Persons Involved in Care: We may use or disclose health information to notify or assist in the notification of (including identifying or locating) 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 incapacity 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. 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. Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, 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. National Security: 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. 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. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practically do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you 50 cents for each page, $20 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.) Disclosure Accounting: 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. Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). We are not Alternative Communication: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. 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 agree to terms & conditions provided by Highpoint Dental. By providing my phone number, I agree to receive text messages from Highpoint Dental. I agree to terms & conditions provided by Highpoint Dental. By providing my phone number, I agree to receive text messages from Highpoint Dental.
