Patient Information First Middle Initial Last SSN: Date of Birth Email Address: City: State: Zip: Home Phone: Cell Phone: Sex: M F Do you prefer appointment confirmations via (check one or both): TEXT MSG or PHONE CALL Marital Status: Single Married Divorced Widowed Separated Employer: Phone Number: Who can we thank for referring you to us? In Case of Emergency Contact Information: Phone: Reason for visiting us today: Pharmacy Name / Number: Allergies: Are you interested in whitening your teeth? Primary Dental Insurance Person Responsible for Account: Relationship to Patient: Date of Birth: SSN: Insurance Company: Subscriber ID: Employer: Group #: Insurance Company Address: Phone:
Notice of Privacy Practices Acknowledgment HIPPA Dove Dentistry 977 State Hwy 121 Suite 190 Allen, TX 75013 972-649-7990 I understand that, under Health Insurance Portability & Accountability Act of 1996 (HIPPA), 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 that treatment directly and indirectly. Obtain payment from third party payers. Conduct Normal healthcare operations such as quality assessments and physician certifications. I have received, read and understand this Notice of Privacy Practice that contains a complete description of the uses and disclosure of my health information. I understand that this organization has the right to change its Notice of Privacy Practice time to time and that I may contact this organization at anytime at the address above to obtain a copy of Notice of Privacy Practice. I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment and or healthcare 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. Patient Name Relationship to Patient: Signature: Date:
General Dentistry Consent Form Dove Dentistry 977 State Hwy 121 Suite 190 Allen, TX 75013 972-649-7990 Treatment to be done I understand that I am to have dental work done as detailed in the attached treatment plan. Dove Dentistry will file your insurance claims, however, you are responsible for all fees which are not paid by your insurance company. Drugs and Medications I understand that antibiotics, analgesics, and other medications can cause allergic reactions such as redness, swelling of tissue, pain, itching, vomiting, and/or analgesic shock (severe allegoric reaction). I have informed the dentist of any known allergies to medications. Women are advised that antibiotics may interfere with the effectiveness of birth control pills. Other means of contraception while taking antibiotics is recommended. X-rays I have been explained about the necessity of taking x-rays to have a thorough comprehensive exam. I will not hold the doctor liable nor responsible if any diagnosis arising without the necessary x-rays. Changes in Treatment Plans I understand that it may be necessary to change or add procedures because of conditions found while working on the teeth. If this occurs the procedure will be stopped and the following changes will be explained to me and new consent form will be signed before continuing with the new treatment. Patient Signature/ Parent / Guardian Date
Cancelation Policy If an office appointment is missed or canceled with less than one business day notice, a $25.00 fee will be assessed to your account. It is very important to notify our office of any cancellation as early as possible so your time slot can be offered to another patient. Your cooperation is appreciated. If a procedure appointment is missed or cancelled with less than two business days notice, a$50.00 fee will be assessed to your account. Any exceptions will be discussed on an individual basis. I have read and understand the cancelation policy for Dove Dentistry. Patient Name Printed: Patient s Signature Date
Ideal Smile Questionnaire Please take a few moments to tell us about your smile. Have you thought about improving the appearance of your smile? Would you like to straighten your teeth? Do you have spaces that you don t like? Would you like to change the color of your teeth? Are your teeth chipped? Are your teeth wearing on the biting surfaces? What would you change about your teeth? (Circle all that apply) Color Shape Size Straighten Other: YES NO mtmclearaligner.com 2017 Dentsply Sirona. All Rights Reserved. RTE-148-17 Issued 5/17 Dentsply International Raintree Essix 7290 26th Court East Sarasota, FL 34243