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

City

State

Zip Code

Add Emergency Details

Emergency Name

Emergency Phone

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 *

26 October 2021 at 02:45 PM by IP 3.238.204.31

Disclaimer

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

Relationship To the Patient*

Name if not the Patient*

Patient or Guardian Signature *

26 October 2021 at 02:45 PM by IP 3.238.204.31

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

Stephen J. Kimball, DMD
7181 Westwind Dr.
El Paso, TX 79912-1781
(915) 581-1511
office@westside-dentistry.com

26 October 2021 at 02:45 PM by IP 3.238.204.31

The billing department understands you have work-related injury and your insurance will pay after we submit all claims. If for any reason your insurance does not cover the procedures performed at our practice, you would be responsible for total amount not covered by your insurance. A bill will be sent if there is an outstanding balance after your claims with the insurance are closed. You would be responsible to pay the balance in timely manner.

Sincerely,

Stephen J. Kimball, DMD

Patient’s Name Patient Coordinator’s Name

Patient’s signature Patient Coordinator’s Signature

Stephen J. Kimball, DMD
7181 Westwind Dr.
El Paso, TX 79912-1781
(915) 581-1511
office@westside-dentistry.com

26 October 2021 at 02:45 PM by IP 3.238.204.31

CONSENT

1. EXAMINATIONS AND X-RAYS

I understand that my initial visit may require radiographs to complete the examination diagnosis and treatment plan. I understand that Westside Dentistry has set standard intervals for radiographs to aid in the diagnosis of oral lesions, decay between the teeth, bone loss, gum disease, cysts, tumors, infections, and impacted teeth.

2. DRUGS, MEDICATION AND SEDATION

I have been informed and understand that antibiotics, analgesics, and other medications can cause allergic reactions causing redness and swelling of tissues, pain, itching, vomiting, and/or anaphylactic shock (severe allergic reaction).

I have informed the Dentist of any known allergies.

I understand that failure to take medications prescribed for me in the manner prescribed may offer risks of continued or exasperated infection, increased pain, and potential resistance to effective treatment of my condition.

I understand that antibiotics can reduce the effectiveness or oral contraceptives (birth control pills), if applicable.

I understand that local anesthesia is utilized to numb tissue for certain dental procedures.

I understand that some patients may experience temporary increased heart rate, allergy, soreness, nerve, or blood vessel bruising, tingling. persistent numbness or trauma after a dental procedure.

Itching, vomiting, and/or anaphylactic shock (severe allergic reaction).

3. CHANGES IN TREATMENT PLAN

I understand that dentistry is not an exact science and that no specific results can be assured or guaranteed.

I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures.

I give my permission to the Dentist to make any and all changes in treatment plan as necessary.

I understand that any associated laboratory fees are my financial responsibility

4. DENTAL PROPHYLAXIS (CLEANING)

I understand the treatment involves the removal of plaque and calculus above the gum line and will not address gum infections below the gum line called periodontal disease. I understand bleeding could last several hours. Should it persist, particularly if it is severe in nature, it should receive attention and this office must be contacted.

5. REQUIRED 30% DEPOSIT ON TREATMENT

I understand that a 30% deposit will be required on all dental treatment prior to scheduling the appointment

6. DENTAL BENEFITS

I understand that my insurance may only provide coverage for the minimum standard of care.

I understand that submitting insurance and receiving a benefit is my responsibility and that any assistance from Westside Dentistry is completely voluntary.

Regardless of the response from my insurance carrier, I elect to follow the Dentist’s recommendation for optimal dental treatment

Stephen J. Kimball, DMD
7181 Westwind Dr.
El Paso, TX 79912-1781
(915) 581-1511
office@westside-dentistry.com

26 October 2021 at 02:45 PM by IP 3.238.204.31