For security purposes, we authenticate your identity using your wireless phone number or email address. You will receive a 4 digit verification code that will need to enter on next page.
Existing patient: Select a name for whom you want to edit details.
Note: We do not share or sell your data. The information you provide is encrypted and directly sent to our system and it is not stored online.
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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.
Patient or Guardian Signature *
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.
Patient or Guardian Signature*
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A copy of our Notice of Privacy Practices was made available and I, [FName] [LName], acknowledge receipt of that notice.
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
NOVEL Coronavirus Disease (COVID-19)Screening Questionnaire Consent Release
Screening: Select Yes or No:
1. Have you traveled internationally in the last 14 days? Yes No2. Have you been in close contact with another person who has been diagnosed with/under investigation for COVID-19? Yes No3. Do you have a cough, fever, or shortness of breath? Yes NoGeneral Release:COVID-19 is the infectious disease caused by the most recently discovered coronavirus. This new virus and disease were unknown before the outbreak began in Wuhan, China, in December 2019.I acknowledge that I have truthfully and honestly answered yes to all the questions above, and I am in the office and receiving this dental treatment of my own free will and volition. The Patient now and forever releases the Practice and any of its affiliated companies, Cincinnati Insurance Company any of its affiliated companies, patients or potential patients, subsidiaries, divisions, and all present and former owners, employees, officers, directors, successors and assigns (whether acting in their individual capacities or as agents for the Practice or a related entity, collectively, the “Released Parties” from any and all Claims against contracting COVID-19 from this office.Consent to Treatment:I understand that being in this office and receiving dental treatment I may be at risk of being infected with COVID-19. As with all social contact at this time, there are risks of contracting COVID- 19.By consenting to treatment, you are acknowledging your willingness to accept known risks and complications of contracting COVID-19 no matter how slight the probability of occurrence.Patient or Representative Signature: