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  • SPOUSE INFORMATION
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  • In the event of an emergency, is there someone who lives near you that we should contact?

  • Medical History

  • For women:
  • Have you ever had any of the following diseases or medical problems?
  • Are you allergic to any of the following?

  • Dental History

  • Do you generally breathe through your mouth?
  • I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during diagnosis and treatment with my informed consent.
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  • Thank you for filling out this form completely

  • This office reserves the right to verify the credit status of potential patients and/or parents of patients prior to extending credit for treatment fees and may, at the discretion of this office, use the services of one or more credit reporting services
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  • Privacy Practices

    This notice describes how medical information about you may be used and disclosed and how you can get access to this information. Please read it carefully. This information is made available upon request by a patient.

    We understand that your dental health information is personal and we are committed to protecting any information about you. As our patient, we create dental records about your dental health, our care for you, and the services and/or Items that we provide to you. By law, we are required to m sure that your Protected Health information is kept private.

    The following are ways In which we could use or disclose your information. All information is shared thru mail, phone or email.

    -For dental treatment

    -For appointment and patient recall reminders

    -In response to requests arising from lawsuits or other disputes

    -To avert a serious threat to health or safety

    -In emergency situations

    -Correspondence to your other dentists office in regards to insurance and/or payment information


    -To run our practice more efficiently and ensure all patients receive quality care

     


    If you believe that your privacy rights have been violated, you may file a complaint with the Practice or with the Secretary of the Department of Health and Human Services. To file a complaint with the Practice, contact the office manager. All complaints must be submitted in writing You will not be penalized for filing a complaint.

    You have certain rights regarding the information that we maintain about you. These rights include:

    -The right to inspect and copy

    -The right to amend

    -The right to request restrictions

    -The right to a paper copy of this notice

    -The right to request confidential communications

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  • Authorization to Disclose Treatment and/or Financial Information

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