Bridgeport Aesthetic Dentistry

Bridgeport Aesthetic Dentistry

New Patient Form
Today's Date

Month Day Year
Date
Patient's Name *

First Name Last Name
Date of Birth *

Month Day Year
Date
Age & Sex *

Age Sex
Social Security # *
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Best Phone Number *

Area Code Phone Number
Cell Phone Number

Area Code Phone Number
Email Address *
Who may we thank for sending you to our office?
Work

Occupation Employer
Phone Numbers

Business Phone Number Cell Phone Number
Marital Status

Minor Single Married Divorced Separated Widowed
Spouse's Full Name

First Name Last Name
Do you have any children? If Yes, how many?

No
ACCOUNT INFO:
Person Responsible for Account *
Relation
Drivers License # *
INSURANCE INFO:
IF YOU HAVE DENTAL INSURANCE, PLEASE COMPLETE INFORMATION BELOW:
PRIMARY DENTAL INSURANCE
Name of Insurance Company
Group # and ID #

Group Number ID Number
Social Security #
This Dental Insurance is provided through:

Name of policy holder Relationship to Patient
Date of Birth

Month Day Year
Date
Insured's Employer
Name of Insurance Company
SECONDARY DENTAL INSURANCE
Name of Insurance Company
Group # and ID #

Group Number ID Number
Social Security #
This Dental Insurance is provided through:

Name of policy holder Relationship to Patient
Date of Birth

Month Day Year
Date
Insured's Employer
Name of Insurance Company
Emergency Contact Info:
Whom should we contact?
Name of Emergency Contact
Relation
How do you know this person
Their Cell Phone Number

Area Code Phone Number
Who is your medical Doctor?
Doctor's Name
Medical Doctor's Phone Number

Area Code Phone Number
Patient Medical History:
Are you currently under the care of a physician? If so, please answer the following:

Name of Physician Date of Last Exam Their Phone Number
Are you under medical treatment now? If Yes, Explain.

No
Have you ever been hospitalized for any surgical operationor serious illness within the last 5 years? If Yes, Explain.

No
Have you ever been hospitalized for any surgical operation or serious illness within the last 5 years? If Yes, Explain.

No
Are you taking any prescription medication?
If Yes, please list all drugs currently being taken.
ARE YOU ALLERGIC TO ANY MEDICATIONS? *
If Yes, please list all allergies separated by a comma.
Do you use controlled substances?

Yes No
Have you ever taken Pen-Phen/Redux?

Yes No
Do you use tobacco?

Yes No
Are you wearing contact lenses?

Yes No
Are you allergic to or have you had reaction to the following? *

Local Anesthetics (e.g. Novocain). Penicillin or any other Antibiotics Sulfa Drugs. Barbiturates Sedarices Any stays in hospital Convuisions/Epilepsy Iodine Aspirin Any Metals (e.g. nickel, mercury, etc None of these
For Women Only:
Are you pregnant or think you may be pregnant?

No
Are you nursing?

No Yes
Are you taking oral contraceptives?

No Yes
Check the box if you have ever had any of the following medical conditions or problems: *

Heart Murmur ADD/ADHDHyperactive Heart problems (any kind) Diabetes Hypertension Convulsions/Epilepsy Gagger Hemophilia Bleeding Problems Hearing Impairment Any Operations Glaucoma Migraines Cancer HIV + /AIDS Rheumatic Fever Hepatitis Latex Allergy High Blood Pressure Swollen Ankles Fainting/Seizures Asthma Kidney Disease Thyroid Problems Cardiac Pacemaker Angina Frequently Tired Anemia Emphysema Arthritis Joint Replacement or Implant Sexually transmitted Disease Stomach Troubles/Ulcers Chest Pains Easily Winded Stroke Hay Fever/Allergies Tuberculosis Radiation Therapy Glaucoma Recent Weight Loss Liver Disease None of these Respiratory Problems
Are you currently under the care of a dentist? If so, please answer the following:

Name of Physician The approx. date of last visit: Their Phone Number
DO YOU NEED TO BE PRE-MEDICATED BEFORE DENTAL TREATMENT? If Yes, Explain.

No
Do your gums bleed while brushing or flossing?

Yes No
Are your teeth sensitive to hot or cold liquids/foods?

Yes No
Are your teeth sensitive to sweet or sour liquids/foods?

Yes No
Do you have any sears or lumps in or near your mouth?

Yes No
Do you feel pain to any of your teeth?.

Yes No
Have you had any head, neck or jaw injuries?

Yes No
Have you ever experienced any of the following problems inyour jaw? Clicking? Pain? Difficulty in opening or closing or chewing?

Yes No
Do you have frequent headaches?

Yes No
Do you clench or grind your teeth?

Yes No
Do you bite your lip or cheeks frequently?

Yes No
Have you ever had any difficult extractions in the past?

Yes No
Have you ever had any prolonged bleeding followingextractions?

Yes No
Do you like your smile?

Yes No
Have you had any orthodontic treatment?.

Yes No
Do you wear denture or partials?

Yes No
Have you ever received oral hygiene instructions regarding the care of your teeth and gums?

Yes No
Authorization and Release:
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payers and/or health practitioners.

I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my dependents.
Sign below: *

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Today's Date *

Month Day Year
Date
Appointment Cancellation Policy:
We strive to render excellent dental care to you and the rest of our patients. In an attempt to be consistent with this, we have an Appointment Cancellation Policy that allows us to schedule appointments for all patients. When an appointment is scheduled, that time has been set aside for
you and when it is missed, that time cannot be used to treat another patient.

Our Policy is as follows:

We require that you give our office 48 hour notice in the event that you need to reschedule your appointment. This allows for other patients to be scheduled into that appointment. If you miss an appointment without contacting our office within the required time, this is considered a missed
appointment. A fee of $50.00 per hour will be charged to you; this fee cannot be billed to your insurance company and will be your direct responsibility. No further appointment can be scheduled nor can records be transferred without the payment of this fee.

Additionally, if a patient is more than 20 minutes late without prior notice for a scheduled appointment, we will consider this a missed appointment and the $50.00 per hour cancellation fee will be charged.

If you have any questions regarding this policy, please let our staff know and we will be glad to clarify any questions you have.
We thank you for your patronage.

I have ready and understand the Appointment Cancellation Policy of the practice and I agree to be bound by its terms. I also understand and agree that such terms may be amended from time-to-time by the practice.
I have received a copy of Bridgeport Aesthetic Dentistry’s Appointment Cancellation Policy.
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Today's Date *

Month Day Year
Date
INSURANCE / FINANCIAL RESPONSIBILITY:
I understand that I am financially responsible for the TOTAL CHARGES of dental services provided. I understand that your office will bill my dental insurance as a courtesy to me. I further understand that if for ANY RESON my insurance / insurances DO NOT cover any charges, I will be FULLY responsible for the charges incurred.
Initials *
I understand that I am responsible for any remaining balance after your office receives payment from my insurance carrier(s).
Initials *
I understand my remaining outstanding beyond 90 days from treatment will bear interest of 1.5% per month or 18% per year.
Initials *
In addition, I understand that if collection proceedings are pursued by your office, I will be responsible for any and all applicable collection fees.
Initials *
As a courtesy, we communicate with your insurance company to verify benefits. We can ESTIMATE what your patient’s portion would be for procedures you might need based on the information provided by your insurance representative, fax, or website. However, sometimes the information provided is incorrect and DOES NOT constitute a guarantee of coverage. Therefore keep in mind; these are “ESTIMATES ONLY”. Benefits are determined upon receipt of actual claims for dental services. It is your responsibility for knowing the provisions and limitations of your policy. You are responsible for ANY payments for fees your insurance does not cover.
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Today's Date *

Month Day Year
Date
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 (04/01/2019), and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice 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 off 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 health 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 reason to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved in Care: We may use or disclose health information to notify, or assist in the notification of (including 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 your professional judgment disclosing only health information that is directly relevant to the person’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.

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 authorize 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 voicemail 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 costbased 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, 2003. 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 (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us:

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Officer: _______________________________________________
Telephone _______________________Fax : ______________________
Email: ______________________________________________________
Address: ____________________________________________________________________________________

© 2002 American Dental Association
All Rights Reserved
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party
requires the prior written approval of the American Dental Association.
This form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).
Acknowledgement of Receipt of Notice of
Privacy Practices

I have received a copy of this office’s Notice of Privacy Practices.
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