New Patient Forms

--- NEW PATIENT FORMS ---
Patient Information, Insurance Information and Health History
Please take a moment to enter or update your information to help us ensure the quality of your care is excellent.
Name *

First Name Middle Name Last Name
Gender *

Male Female
Family Status *

Married Single Child Other
Birth Date *

Month Day Year
Date
SS# *
Previous Visit *

Month Day Year
Date
Email Address *
example@example.com
Best time to call *
Home Phone Number *

Area Code Phone Number
Mobile Phone Number *

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Fax Number

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Spouse/Responsible Party Information:
The following is for *

the patient's spouse the person responsible for payment both neither-not applicable
Name *

First Name Last Name
Gender *

Male Female
Family Status *

Married Single Child Other
Birth Date *

Month Day Year
Date
Email Address *
example@example.com
Best time to call *
Home Phone Number *

Area Code Phone Number
Mobile Phone Number *

Area Code Phone Number
Work Phone Number

Area Code Phone Number
Address *

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insurance Information
Name of Insured

First Name Last Name
Insured's Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Insured's Birth Date

Month Day Year
Date
ID #
Group #
Insured's Employer Name
Employer Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
Patient's relationship to insured

Self Spouse Child Other
Insurance Plan Name
Insurance Address

Street Address

Street Address Line 2

City State / Province

Postal / Zip Code
INSURANCE AUTHORIZATION

By checking this box, I authorize Telluride Dental to release necessary information to my dental insurance company to secure the payment of benefits. I authorize the use of this signature on all insurance submissions and hereby authorize the insurance company to pay benefits directly to Telluride Dental or Dr. Ryan Grady
Health History
1. Please list your present health concerns, problems or symptoms: *
2. When was your last Dental visit and what was done at this time? *
3. How do you feel about the appearance of your teeth? *
4. When was your last Physical exam? *
5. Physician's Name, Phone Number, and Address: *
6. Are you currently under medical treatment? If yes, please describe. *
7. Have you ever had any serious illnesses or operations? If yes, please describe.
8. Are you currently taking any medication(s) including non-prescription medicine? Please list. *
9. Do you smoke or use tobacco products? If yes, how much a week? *
10. Do you use alcohol? If yes, how much a week? *
11. Do you have artificial or replacement joints, knee, hip, etc? If yes, please list. *
12. Do you have any allergies (food, medications, etc)? If yes, please list. *
Please check all that apply: *

*Pre-Med - Amox *Pre-Med - Clind *Pre-Med - Other Addiction to Drugs Allergy - Anesthesia Allergy - Aspirin Allergy - Codeine Allergy - Erythro Allergy - Hay Fever Allergy - Latex Allergy - Other Allergy - Penicillin Allergy - Sulfa Anemia Angian/Chest Pain Arthritis Artificial Joints Asthma Bleeding Tendency Blood Disease Cancer Current Breast Feeding Diabetes Dizziness Emphysema Epilepsy Excessive Bleeding Fainting Glaucoma Head Injuries Heart Attack Heart Disease Heart Murmur Heart Stent Hepatitis Herpes HIGH ANXIETY High Blood Pressure HIV / AIDS Kidney Disease Liver Disease Lupus (SLE) Medications Mental Disorders Mitral Valve Prolapse Nervous Disorders New Heart Valve Osteoporosis Other Pacemaker Pregnancy Radiation Treatment Respiratory Problems Rheumatic Fever Rheumatism Shortness of Breath Sinus Problems Stomach Problems Stroke Take Bisphosphonates Thyroid Tuberculosis Tumors Ulcers NONE
Please describe any other medical conditions that were not previously asked. *
Name of person, office, or other source referring you to our office: *
Signature of patient, parent, or guardian (responsible party):
Name *

First Name Last Name
Date *

Month Day Year
Date
Relationship to Patient *
Signature *

Clear
COVID-19 Pandemic Patient Disclosures
This patient disclosure form seeks information from you that we must consider before making treatment decisions during the COVID-19 virus outbreak A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19.

Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us. It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

Type a question *

YES

Do you have or have you had a fever or above normal temperature?

Have you experienced shortness of breath or had trouble breathing?

Do you have a dry cough?

Do you have a runny nose or other flu like symptoms?

Have you recently lost or had a reduction in your sense taste or smell?

Do you have a sore throat?

Have you been in contact with someone who has tested positive for COVID-19?

Have you tested positive for COVID-19?

Have you been tested for COVID-19 and are awaiting results?

Have you traveled outside the United States by air or cruise ship in the past 14 days?

Have you traveled within the United States by air, bus or train within the past 14 days?

I fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Signature *

Clear
Dental Treatment Consent and Affirmation Form
I knowingly and willingly consent to dental treatment at Telluride Center for Dentistry by Dr. Grady, Dr. Kopasz, Heidi Weaver and Lynsey Bonebrake and any designated associates and employees during the reopening phase of COVID-19.

I understand the COVID-19 virus has a long incubation period during which carriers of the virus may not show symptoms yet are still highly contagious. It is impossible to determine who has COVID-19 and who does not given the current limitations and availability in COVID-19 viral testing.

Risk of transmission: I understand that due to the frequency of visits of other care dental patients, characteristics of the virus, and the characteristics of dental procedures, that I have an elevated risk of contracting the virus simply by being in a dental office, even though standard precautions are being observed.

I am unaware of being a possible carrier or infected: I confirm that I have not tested positive for COVID-19 in the last 30 days and that I am not presenting with any of the following symptoms of COVID-19:
- Fever of 100.5 degrees Fahrenheit or 37 degrees Celsius or higher
- Shortness of breath
- Dry cough
- Runny nose
- Sore throat
- Diminished sense of taste or smell
Contact with infected: I confirm that I have not knowingly been in close contact (defined as 6 feet or less for a duration of fifteen minutes or more) with someone who has tested positive for COVID-19 in the last 14 days, or with anyone that has had the above stated symptoms in paragraph 4 (#4) in the last 14 days.

Public travel: I confirm that I have not traveled outside of the United States in the past 14 days. I confirm that I have not traveled domestically by commercial airline, bus, or train within the last 14 days.

INFORMED CONSENT: I have been given the opportunity to ask any questions regarding the risks of contracting COVID-19 from the dental office and dental procedures. I reaffirm that I am not a carrier of COVID-19 nor infected with COVID-19 to the best of my knowledge. I voluntarily assume any and all medical/dental risks, including the substantial and significant risk of serious harm, if any, which may be associated with any phase of my treatment as a result of the COVID-19 pandemic. I acknowledge that the nature and purpose of the dental procedures recommended under the current circumstances and restrictions have been explained to me and that I have been given the opportunity to ask questions.
Date *

Month Day Year
Date
Signature *

Clear
Informed Consent for General Dental Procedures
You, the patient, have the right to accept or reject treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedures, alternative treatments, or the option of no treatment.

Do not consent to treatment unless and until you discuss potential benefits, risks and complications with your dentist and all your questions are answered. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the probability of occurrence.

It is very important that you provide us with accurate information before, during and after treatment. It is equally important that you follow your dentists advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentist or specialist, and return for scheduled appointments. If you fail to follow the advice of the dentist, you may increase chances of a poor outcome.

Certain heart conditions may create a risk of serious or fatal complications. If you have a heart condition or heart murmur advise your dentist immediately so he can consult with your physician if necessary.

If you are a woman on oral birth control medication you must consider the fact that antibiotics might make oral birth control less or non effective.

Do not sign this form or agree to treatment until you have read, understood, and accepted each paragraph stated above. Please discuss the potential benefits, risks, and complications of recommended treatment with your dentist. Be certain all of your concerns have been addressed to your satisfaction by your dentist before commencing treatment.
HIPAA (Health Insurance Portability Accountability Act) - Notice of Privacy Practices Patient Agreement
Protecting your private information is our priority.

Your protected health information may be used and disclosed by our staff and others outside of our office that are involved in your care and treatment for the purpose of providing dental care services for you, to pay your health care bills, to support the operation of the doctor's practice, and any other use required by law.

Treatment: We will use and disclose your protected health information to provide, coordinate, or manage your dental care.

Payment: Your protected health information will be used, as needed, to obtain payment for your dental care. (such as pursuing payment from an insurance company)

Healthcare Operations: We may use or disclose, as needed, your protected health information in order to support the business activities of your dentist's practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of dental staff, licensing, and conducting or arranging for other business activities. In addition, we may call you by name in the waiting room when your dentist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.

We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required By Law, Public Health issues as Required By Law, Communicable Diseases: Health Oversight: Abuse or Neglect: food and Drug Administrations requirements: Legal Proceedings: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Workers Compensation: Inmates: Required Uses and Disclosures: Under the Law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of Section 164.500.

Other Permitted and Required Uses and Disclosures will be made only with YOUR consent (or if you are a minor - the consent of a legal parent or guardian), Authorization or Opportunity to Object unless required by law.

I have received this practice's Notice of Privacy Practices (HIPPA FORM) written in plain language. This notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights and the practice's legal duties with respect to my protected health information. The notice includes:
1. A statement that this practice is required by law to maintain the privacy of protected health information.
2. A statement that this practice is required to abide by the terms of the notice currently in effect.
3. Types of uses and disclosures that this practice is permitted to make for each of the following purposes: treatment, payment and health care operations.
4. A description of each of the other purposes for which this practice is permitted or required to use of disclose protected health information without my written consent or authorization.
5. A description of uses and disclosures that are prohibited or materially limited by law.
6. A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization.
7. My individual right with respect to protected health information and brief description of how I may exercise these rights in relation to:
- The right to complain to this practice and to the Secretary of HHS if I believe my privacy rights have been violated, and that no retaliatory actions be used against me in the event of such a complaint.
- The right to request restrictions on certain uses and disclosures of my protected health information, and that this practice is not required to agree to a requested restriction.
- The right to receive confidential communications of protected health information.
- The right to inspect and copy protected health information.
- The right to amend protected health information.
- The right to receive an accounting of disclosures of protected health information.
- The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request.
This practice reserves the right to change the terms of this Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains.

I understand that I can obtain this practices current Notice of Privacy Practices upon request.
Financial & Cancellation Policy
Payment is expected at the time of service.

If you have Insurance, we will bill your insurance company for their part and collect your co-pay amount from you at the time of service. Insurance is ESTIMATED and if your insurance does not pay as much as we estimate, you will be responsible for the difference.

*You are responsible to know what your insurance company will cover, they will tell their insured more than they will tell a provider. We do our best to collect as much information about your coverage as we can. Therefore we can only relay to you what they tell us. (*As a courtesy, we bill many different insurances, it is diffucult to know exactly what your insurance will cover. If you need to know exactly, we are happy to file a Pre-Determination Estimate with your insurance company... again, Insurances also use "Estimated" benefits on their Predetermination Benefit Vouchers). Insurance companys also use the terminology "Usual and Customary Fee", insurance companys will not tell you what their usual customary fee is, every insurance company has a different Usual and Customary fee and it will reflect on their explanation of benefits after a claim is submitted.

For more comprehensive treatment plans, ask about CARE CREDIT*, which allows you to pay over 6 or 12 months interest free with credit approval.

Telluride Dental accepts the following options for payment:
- Cash
- Check
- Visa
- Mastercard
- American Express
- Discover
- Care Credit
A fee of $25 is charged for non-sufficient funds (NSF) checks.

A fee of $49 is charged for confirmed appointments missed or not canceled within 24 hours of the appointment.

By Signing Below, I understand and agree to Telluride Center for Dentistry's Informed Consent for General Dental Procedures, HIPAA (Health Insurance Portability Accountability Act) - Notice of Privacy Practices Patient Agreement and FINANCIAL AND CANCELLATION POLICY.
Name *

First Name Last Name
Date *

Month Day Year
Date
Signature *

Clear
Should be Empty:

--- NEW PATIENT FORMS ---

Patient Information, Insurance Information and Health History

Spouse/Responsible Party Information:

Insurance Information

Health History

COVID-19 Pandemic Patient Disclosures

Dental Treatment Consent and Affirmation Form

Informed Consent for General Dental Procedures

HIPAA (Health Insurance Portability Accountability Act) - Notice of Privacy Practices Patient Agreement

Financial & Cancellation Policy