Personal Details

Title

First Name*

Last Name*

Preferred Name

Date of Birth (mm/dd/yyyy)*

SSN

Gender

Home Phone

Mobile Number*

Can we contact you via SMS/Text?

?? Yes No

Language

How did you hear about us?

Other reference name*

Add Address Details

Address

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Emergency Name

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Do you have Insurance?

Yes

Upload insurance documents

Relationship to patient*

Insured Birth Date (mm/dd/yyyy)*

Subscriber ID*

Group Number

Insured Social Security Number

First Name of Insured*

Last Name of Insured*

Employer Name

Ins Company*

Other Ins Compay

Disclaimer

I understand that I am financially responsible for any charges not covered by my benefits. It is my responsibility to notify office of any changes to my benefits. In some cases, exact insurance benefits cannot be determined until the insurance company receives the claim. I am responsible for the entire bill or balance of the bill if the submitted claims or any part of them are denied for payment. I understand that by signing this form I am accepting financial responsibility as explained above for all payment for products and services received. I authorize office to submit insurance claims on my behalf and to release information necessary to my insurance company for the processing of those claims. I assign all dental benefits for services rendered and authorize and direct my insurance carrier(s) to issue payment directly to office. I certify that the information I have provided is accurate to the best of my knowledge.

Relationship To the Patient*

Name if not the Patient*

Patient or Guardian Signature *

23 June 2021 at 05:20 AM by IP 44.192.253.106

Notice of Privacy Policies

Acknowledgement of Receipt of Notice of Privacy Practices

A copy of our Notice of Privacy Practices was made available and I, [FName] [LName], acknowledge receipt of that notice.

Electronic Data

Do we have your permission to transmit your information by conventional email to other offices for referrals or communication? There may be some level of risk that the information in these emails could be read by a third party. We currently use a HIPAA compliant encrypted email service.

I have had the full opportunity to read and consider the contents of the Notice of Privacy Practices. I understand that I am giving my permission to your use and disclosure of my protected health information in order to carry out treatment, payment activities, and healthcare operations. I also understand that I have the right to revoke permision.

Patient, Parent or Guardian's Signature

Doctor Signature

Indian Trail Dental Studio
4514 Old Monroe Rd
Indian Trail, NC 28079
(704) 839-2434

23 June 2021 at 05:20 AM by IP 44.192.253.106

Date:
Dental Treatment Consent
Last Name:
First Name:
Birthdate:

1. Diagnostic and Preventive I understand that I am having the following work done: X Rays Cleaning Scaling Initials:

2. Drugs and Medications I understand that antibiotics and analgesics and other medications can cause allergic reactions resulting in redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction). Initials:

3. Local Anesthetic I understand there are risks associated with local anesthesia that may affect my body such as dizziness, nausea, vomiting, accelerated heart rate, slow heart rate, or various types of allergic reactions. It may also cause injury to nerves that can result in pain, numbness, and tingling that may persist for several weeks, months, or rarely, be permanent. I have informed my doctor of my complete medical history including any recent surgeries or changes. Initials:

4. Crowns and Bridges I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. It is my responsibility to return within one month of tooth preparation for final cementation of the restoration. Initials:

5. Dentures, Complete or Partial I realize that full or partial dentures are artificial teeth, constructed of plastic, metal, and/or porcelain. The complications of wearing these appliances have been explained to me. These include looseness, soreness, and possible breakage. I realize the final opportunity to make changes in my new dentures will be the “teeth in wax” try-in visit. I understand that most dentures require relining approximately three to twelve months after initial placement. Initials:

6. Endodontic Treatment (Root Canal) I realize there is no guarantee that root canal treatment will save my tooth, and that complications can occur from the treatment, and that occasionally metal objects are cemented in the tooth or extend through the root, which does not necessarily affect the outcome of the treatment. I understand that an undetectable “hairline” crack in a tooth may cause failure, no matter how extensive therapy may be. A small percentage of root canals fail despite the best efforts. I understand that specialty care may be indicated if complications arise, such as the need for an apicoectomy. Initials:

7. Fillings I understand that care must be exercised in chewing on fillings the first 24 hours to avoid breakage. I understand that a more extensive restoration than originally planned may be due to additional conditions discovered during preparation. I understand any time a tooth is prepared, for any reason, there is always irritation to the nerve of the tooth, which may result in post-operative sensitivity or, in some cases, permanent nerve damage requiring a root canal. Initials:

Office policy requires payment in full for all services rendered at the time of visit, unless other arrangements have been made with the business manager. I authorize the staff to perform any necessary services needed during diagnosis and treatment. I also authorize the provider to release any information required to process insurance claims. I acknowledge that no guarantee has been made by anyone regarding the dental treatment by which I have requested and authorized. I have had the opportunity to read this form and ask questions. I consent to the proposed treatment.

Patient/Guardian Signature

23 June 2021 at 05:20 AM by IP 44.192.253.106