DENTAL HISTORY AND CONSENT FOR TREATMENT

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1 DENTAL HISTORY AND CONSENT FOR TREATMENT Reason for seeking dental care at this time of last dental visit Reason? of last X-rays Former dentist City/state How often do you: Brush times per Floss times per How do you feel about dental treatment? Relaxed A little uneasy Tense Anxious Very Anxious Do you have or have you ever had any of the following? Please mark boxes and comment. Aching or sensitive teeth Broken filling Areas of food traps Unfavorable dental experience Sensitive or bleeding gums Loose teeth Difficulty opening wide Growths or lesions in your mouth Broken or missing teeth Bad breath Clicking or popping in jaw Cold sores Grinding or clenching Swollen glands Jaw pain or tiredness Dry mouth Swelling or lumps in mouth Gum infection Orthodontic treatment Other If you could change your smile, what would you change? Remove unsightly fillings Straighten teeth Change shape of teeth Close gaps between teeth Replace missing teeth Whitening Make teeth same color Other Consent I, the undersigned, hereby authorize the doctor to take radiographs, study models, photographs or any other diagnostic aids he/she deems appropriate to make a thorough diagnosis of my dental needs. I also authorize the doctor to perform any and all forms of treatment, medication and therapy that may be indicated. I authorize and consent that the doctor employ any such assistance as he/she deems appropriate. I further authorize the release of any information, including the diagnosis, radiographs and records of any treatments or examinations rendered to my insurance company, consulting professionals or others that may request my records. I understand that I am personally responsible for payment of all fees for dental services provided in this office for me or my dependents, regardless of insurance coverage. Breach of this responsibility carries the penalty of compensating the practice for any related attorney s and collection fees. I understand that payment is due when services are rendered. Any other arrangements for payment must be made before treatment begins. Signature of patient or Relationship authorized responsible party DENTAL HISTORY AND CONSENT FOR TREATMENT

2 Primary insurance Insured s name Insurance company Address Secondary insurance Insured s name Insurance company Address Phone Phone Union or Local # Union or Local # Group Group Social Security # Social Security # Insurance agreement I certify that the above insurance information is correct and in force. I am aware that it is my responsibility to read and understand my own dental insurance policy, including benefits, limitations and exclusions. I understand that filing of insurance claims is my responsibility and may be provided as a service to me and that any agreement for dental coverage is between my insurance company and myself. I understand that an estimated portion is due at time of service and is estimated according to expected coverage, which may not be disclosed nor guaranteed, by my insurance company. I understand my portion may be more if my insurance company does not pay the anticipated amount. I also understand that services are rendered independent of insurance reimbursement. Signature of responsible party

3 PATIENT HISTORY Patient Information Last First Middle Address City State Zip Home phone Work phone Birthdate Age M / F By What Name do you wish to be addressed? SS # Occupation Guardian s name if patient is a minor Whom may we thank for referring you? In case of emergency, contact Name Billing Information Person responsible for this account Address City State Zip Home phone Work phone Birthdate Age M / F SS # Drivers Lic # Occupation Years at this job Single Married Widowed Divorced YY / MM How do you prefer to handle this account? (after insurance, if applicable) Cash Credit Card Other Spouse s Name Birthdate Relationship Home Phone Work Phone Medical History Are you currently under a physician s care? Yes No If so, for what reason? Work phone Physician s Information Dr s Name Address City State Zip Phone Please mark any of the following you may have had, or have at present Rheumatic Fever Heart Murmur Congenital Heart Disease Artificial Heart Valve Pacemaker High / Low Blood Pressure Heart Attack or Heart Disease Blood thinning treatment HIV or AIDS Hepatitis or Liver Disease Venereal Disease Inner Ear disorders or Surgery Medications List all medications and dietary supplements you have taken in the last 3 months. Include dosage and reason for taking the medication Artificial Joint Surgical Prosthesis Ulcers/Stomach problems Cancer or related treatment Kidney trouble Diabetes Glaucoma Scarlet Fever Thyroid Disease Tuberculosis Arthritis / Rheumatism Stroke Epilepsy or seizures Fainting or dizzy spells Psychiatric treatment Leukemia Bruise easily Asthma Hay Fever Emphysema Allergies or Hives Sinus trouble Cold sores or herpes Other Do you or have you used: Tobacco Yes No Alcohol Yes No Illegal IV drugs Yes No Other For women only- Are you pregnant? Yes No Are you nursing? Yes No Do you take birth control? Yes No Have you ever been requested to take antibiotics or other medications before a dental appointment? Yes No Is there anything else we should know about your health that is not covered in this form? Yes No Would you like to speak with the doctor privately about any matter? Yes No I certify that the above information is complete and accurate Allergies Mark all medications or health care related substances to which you have experienced an allergic or adverse reaction: Penicillin Sulfa drugs Others Codeine Epinephrine Latex Local Anesthetics None Patient Signature Patient Signature PATIENT HISTORY

4 Geelan Dental Care Office Financial Policy Thank you for choosing our office and allowing us to serve you as your dental health care provider. In the interest of a good health care practice, it is desirable to establish an office and financial policy to avoid misunderstandings. Our primary responsibility is to help our patients experience good health and we wish to spend our time and energy toward that end. The following is a statement of our policy, which we ask that you read and sign prior to any treatment. Payment for services rendered will be due at the time of service. We accept cash, check, Visa, Mastercard & Discover. Payment Options Option #1 - A 5% discount will be given for paying your estimated out-of-pocket expense in full at the time of your appointment. Option #2 You may opt to pay 50% of your out-of-pocket estimate at the time of your appointment and pay off the balance within 60 days. Option #3 - Financing through Care Credit is available on approved credit. They offer 0% interest plans for 6 or 12 months. Please ask for details if interested. Regarding Insurance As a courtesy to our patients, we are happy to submit the claims necessary to see that you receive the full benefits of your coverage. Please understand that we will provide an insurance estimate to you, however, it is not a guarantee that your insurance will pay exactly as estimated. All charges you incur are your responsibility regardless of your insurance coverage. Your insurance company and your plan benefits ultimately determine the amount paid. We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your insurance company. Your insurance policy is a contract between you, your insurance company, and in many cases, your employer. We must have the following information to bill your insurance: name & address of insurance company, the insured s ID number or social security number, insured s date of birth, address, and employer s name. 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. Insurance payments are ordinarily received within days from the time of filing. If your insurance company has not made payment within 60 days, we ask that you contact your insurance company to make sure payment is expected. If payment is not received or your claim is denied, you will be responsible for paying the full amount at that time. Billing All accounts with balances that have not been paid within 60 days will incur a monthly 1.5% finance charge (18% per annum). In the event that it becomes necessary to refer your account to a collection agency, you agree to be responsible for and pay a $50 collection fee and any legal fees resulting from the referral to the collection agency. There is also a $25 returned check fee. Refunds Any refunds for overpayment will be sent after all treatment is completed and insurance has been collected. Missed Appointments If you are unable to keep a scheduled appointment, we kindly ask that you give two business days notice so that we can make every effort to accommodate other patients. If proper notice is not received, there will be a $50 charge to your account. Our business days are Monday-Thursday 8:00am-5:00pm. AS A PATIENT OR LEGAL GUARDIAN TO A MINOR PATIENT, I HAVE READ, UNDERSTAND AND AGREE TO THE ABOVE TERMS & CONDITIONS. I AUTHORIZE MY INSURANCE COMPANY (if applicable) TO PAY MY DENTAL BENEFITS DIRECTLY TO GEELAN DENTAL CARE. Patient or responsible party signature

5 [ELAN DENTAL CARE LLC NOTICE OF PRIVACY PRACTICES THIS 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 (MMOD/YR), and will remain in effect until we replace it. V i e reserve the right to change our privacy practices and the terms of this Notic., -e 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 haalth 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 aoree that we may do so. Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of tincludino 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 rialevant to the oerson'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. Phone: Fax: SW Main, Suite 290, Portland, OR arongeelandmd@comcast.net

6 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, 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. 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 voic 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 practicably 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 $0. for each page, $ 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, 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. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request. Amendment: 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 ( ), you are entitled to receive this Notice in written form.

7 EELAN DENTAL CARE LLC CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION SECTION A: PATIENT GIVING CONSENT Name: Address: Telephone: Patient #: Social Security #: SECTION B: TO THE PATIENT PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this Consent. We encourage you to read it carefully and completely before signing this Consent. We reserve' he right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at anytime by contacting: Contact Person: K Mber Telephone: Fax: Address: 101 SW Main St #290 Portland, OR Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact Person listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent. SIGNATURE I. have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy Practices. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and health care operations. Signature: : If this Consent is signed by a personal representative on behalf of the patient, complete the following: Personal Representative's Name: Relationship to Patient: YOU ARE ENTITLED TO A COPY OF THIS CONSENT AFTER YOU SIGN IT. Include completed Consent in the patient's chart. Phone: I Fax: I 101 SW Main, Suite 290, Portland, OR I arongeelandmd@comcast.net

PATIENT REGISTRATION & HEALTH HISTORY FORM

PATIENT REGISTRATION & HEALTH HISTORY FORM 133 E Main Street, Carlton, OR 97111 Phone: (503) 852-7147 Date: PATIENT INFORMATION First Name: M: Is the patient a student? Full Time Part Time Last Name: Employer: