CARLOWDENTALCENTRE-NEW PATIENT INFORMATION

Please provide us with your personal details for our patient records

NAME*

DATE OF BIRTH*

Date

ADDRESS*

Eircode*

MOBILE NUMBER*

LANDLINE

NEXT OF KIN*

CONTACT NUMBER*

EMAIL ADDRESS*

example@example.com

OCCUPATION*

Also, for marketing and sales purposes, we would like to ask how you heard about the Clinic*

We store patient information in line with the GDPR Regulations (EU) 2016/679; we only request personal data for our patient charts and only share data with third parties if it is for medical reasons with the patient's

We value our patients and appreciate you choosing us as your dental care provider. However, if you need to cancel or change your appointment, please give us at least 24 hours' notice. Your appointment time has been especially reserved for you and keeping your appointment helps us to maintain an efficient schedule for our practice and for other patients. We would also like to draw your attention to the fact that during the treatment dentists may communicate with each other in Hungarian in order to ensure professional accuracy. Of course you will be informed by your dentist about everything related to your treatment in English. The balance of all procedures and services rendered are payable on the day of the procedure. We accept cash, bank draft and credit / debit card payments. Please note that all digital records taken at the Clinic are the properties of the Clinic.

Date*

Date

Patient's signature*

CANCELLED AND FAILED APPOINTMENTS POLICY

Cancelled Appointments

To ensure the smooth running of the practice, Carlow Dental Centre requires at least 24 hours'notice when cancelling an appointment. This allows us to reallocate your appointment to patients who may be in pain. Please be considerate and if, for any reason, you are unable to attend your appointment please notify the practice at your earliest convenience by phoning reception on 0599173762

Failure to do so will incur a charge of €25.00 for every 15 minutes allocated to your appointment. Please note that cancelling an appointment is likely to result in a delay in your treatment due to our busy appointment schedule.

Failing an Appointment

Failing an appointment causes great disruption at the practice. It will incur a charge of €25.00 for every 15 minutes allocated to your appointment in all cases. The Practice Manager has thediscretion to waive the charge in very exceptional circumstances and may require documented evidence to support any such claim. The duration of your appointment(s) can be found on your receipts.

We reserve the right not to offer you future treatment if you continue to miss appointments.

If the failed appointment is part of a course of treatment, Carlow Dental Centre reserves the right to cancel any subsequent appointments to avoid further cost to the practice. This can be avoided by paying the charge in full, as soon as possible after the failed appointment and providing the practice with confirmation that future appointments will be attended. You may be asked to pay a deposit in advance

We will not be able to schedule further appointments until outstanding amounts are paid in full.

I have read and understand the above policy document on cancelled and failed appointments and agree to pay any charges that may be incurred.

Date*

Date

Patient's signature*

FINANCIAL POLICY

Thank you for choosing us as your dental care provider. Our clinic is committed to providing you with the best possible care. Please understand that payment of your bill is considered as part of your treatment. The following is a statement of our Financial Policy which we require you to read and sign prior to any treatment. All patients must complete our Information Sheet before seeing the doctor.

Regarding Payment

We accept cash, bank draft and laser / credit card payments.

A fixed deposit fee will be required within 72 hours of booking your appointments to avoid release. These are as follows:

Department Apt length Fee
General Dentist 60mins / 120+mins €200 / €500
Oral Surgeon All primary appointments €500
Periodontist All primary appointments €300

The remaining balance for services is due at the time services are rendered including our oral surgeons, periodotist and orthodontists unless prior arrangements have been made with the doctor and the billing receptionist. If dentures, partial dentures, crowns and bridges are to be fabricated by a dental laboratory, a further 50% deposit will then be required at your first appointment. The remaining balance is due at the time the prosthesis is cemented or inserted.

The parent that accompanies the minor child/children to the appointment is responsible for any payment due. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized before the appointment date or previous arrangements have been made with the doctor and billing receptionist. Our practice is committed to providing the best treatment for our patients and we charge what is the usual and customary for our area. You are responsible for payment regardless of any circumstances.

We would be happy to discuss our charges and how they relate to your particular situation. We also realize that temporary financial situations may affect timely payment of your account. If such problems do arise, we encourage you to contact us promptly for assistance in the management of your account.

Thank you for understanding our Financial Policy. Please let us know if you have any questions or concerns.

Date*

Date

Patient's signature*

DENTAL PAYENT OPTIONS

Dental health is a great investment into your overall physical and psychological well being. Financial considerations should not be an obstacle to obtaining this important health service. However, we know that people have different needs in fulfilling their financial obligations. For this reason, we provide the following payment options:

Prepaid Payment Plan - Should you wish to make advance payments prior to your treatment commencing we can run a credit on your account. When payment equals the entire amount due for treatment, treatment can then begin.

Payment in Full - Ask about our 5% courtesy discount for full payment of your treatmentplan in advance, at the start of treatment for treatment plans over €1000.00.

Flex-Fi Finance* - Flexi-Fi is an instalment payment plan facility that will allow you to spread out the cost of your dental treatment over 2/3yrs but won't delay your treatment. Approval takes 20/30mins and application can be completed from the comfort of your home on your mobile or tablet device. Please ask one of our reception team for more details. * Admin fees on behalf of Carlow Dental Centre also apply.

PATIENTS WITH DENTAL INSURANCE

We welcome patients who have dental insurance. However, we are not registered members of any dental insurance company and do not claim any benefits on the patient's behalf. All claims must be processed on a pay and claim basis. It is up to each individual to ensure that they can claim directly from their dental insurance provider. We are more than happy to complete the necessary paperwork and provide you with detailed receipts to facilitate your claim.

CONSENT AND WAIVER FOR OBTAINING DIAGNOSTIC RECORDS

Patient name*

Date of birth*

Date

I hereby authorize and consent to the initial diagnostics data gathering and the use of diagnostic records, including but not limited to, OPG panoramic, periapical and cephalogram x-rays, CBCT scan(cone beam computed tomography), diagnostic study models, digital scanning and other images, digital intraoral and full facial photos and videos taken at the Carlow Dental Centre. I hereby grant them permission to reproduce, publish, print, use and distribute copies of such photographs/x-rays

Please note that digital full facial and / or intraoral photography taken during treatment is used by our laboratories for cosmetic purposes in the fabrication of crowns, bridges, partials restorations, veneers, dentures, and orthodontic treatment. These images will be retained as a part of your permanent dental record.

I do consent to the use of digital photos or x-rays (as detailed above) and CBCT scan in dental treatment and these records are strictly for use in my plan of care. *

Yes

I understand these records will remain the property of Carlow Dental Centre. I further understand I will be required to sign a release of records authorization upon request.

If, in the future, you wish to withdraw this consent, you have the right to do so at any time by letting us know in writing.

Date*

Date

Patient's / Guardian's signature*

Patient name*

Date of birth*

Date

We need your permission to take and use clinical photographs of your mouth and face. This statement explains how your digital images and photographs may be used.

Clinical photographs play a key role in the education of patients and staff. In this way they can improve the care of future patients.
If you wish to withdraw this consent at any time in future, you may do so by writing to the practice.
Your decision to consent, or refusal to consent, to points below, marked a, b or C below will not affect your treatment. Level d consent is required for all images we take from part of your confidential treatment record.
Additional patient records we take include but are not limited to, OPG Panoramic or periapical x-rays, diagnostic study models, videos taken at the Carlow Dental Centre. You hereby grant them permission to reproduce, publish, print, use and distribute copies of such photographs/x-rays either in an official medical publication or in lectures for educational purposes.

Please read the following and tick 'Yes' or 'No'. If you do not fully understand any of the sentences below please ask a member of staff to explain.

a. I understand that the Full Face images taken may be used for publication in a journal, textbook, as part of a display or information leaflet or an open access web site, which may be seen by the general public as well as dental professionals. I consent to this use:*

YesNo

b. I understand that the Teeth Only images taken may be used for publication in a journal, textbook, as part of a display or information leaflet or an open access web site, which may be seen by the general public as well as dental professionals. I consent to this use:*

YesNo

c. I understand the images taken may be used for the purpose of dental teaching and research textbook, as part of a display or information leaflet or an open access web site, which may be seen by the general public as well as dental professionals. I consent to this use:*

YesNo

d. I understand the images taken will form part of my confidential treatment record and I consent*

YesNo

Date*

Date

Patient's / Parent's or Guardian's signature*

GDPR STATEMENT - CARLOW DENTAL CENTRE (CDC) LTD.

On 25 May 2018, the General Data Protection Regulation (GDPR), a new Europe wide data protection regulation comes into effect. This new regulation seeks to strengthen and unify data protection for all individuals within the European Union and grants new and enhanced rights for individuals in relation to their personal information.

What does GDPR mean for you / your child?

GDPR increases and reinforces the rights of individuals in relation to the information we hold about them. Being transparent and providing accessible information to patients / parents and guardians about how we process our patient's personal information is a key element of the new regulation. We take privacy and the protection of customer data very seriously. We have always attached the highest importance to the security of our patients' information and will continue to do so going forward. We fully support the enhancements to Data Protection which GDPR will introduce and we have been actively working to implement the changes required to be ready for the new regulation. We include our updated privacy policy and outline our commitment to you / your child under the GDPR in our GDPR Privacy statement which is located on our website www.carlowdentalcentre.ie

Declaration

In line with this new regulation, we wanted to take this opportunity to provide you with more information about the personal information we hold, how we use your / your child's personal information and the rights you have in relation to your / your child's personal information. This is explained in our declaration which can be accessed via our website at www.carlowdentalcentre.ie

Updated Agreement

We have made minor updates to your terms and conditions to reflect GDPR at our new patient information sheets which can be accessed and requested through our Data Protection Officer via email at reception@carlowdentalcentre.ie

What do you need to do?

No further action is required by you.

Need more information?

If you have any further questions about anything covered here, please contact us

at reception@carlowdentalcentre.ie with GDPR placed in the subject field and our

dedicated Data Protection Officer will be in contact with you.

Date*

Date

Patient's / Parent's or Guardian's signature*

1. Name*

Date of birth*

Date

2.Contact telephone number*

3. Current medications please list frequency and dosage of all medications

4.What kind of medicines do you take regularly or have you taken in the past few days?

Other

5. Have you taken any medicine in the last 3 months?*

YesNo

6. Do you suffer from any of the following diseases? (Please circle yes or no)

Diabetes*

YesNo

Osteoporosis *

YesNo

Bleeding disorder*

YesNo

Bleeder*

YesNo

Thyroid gland functional problems*

YesNo

Respiratory (organs) system disorder*

YesNo

Nervous system problems*

YesNo

Cardiovascular system problems*

YesNo

Epilepsy*

YesNo

Articular problems*

YesNo

Communicable disease*

YesNo

HIV *

YesNo

Hepatitis*

YesNo

TB*

YesNo

Asthma *

YesNo

7. Do you have any allergies?*

YesNo

If yes, please explain

8. Are you allergic to any medicine?*

YesNo

If yes, please explain

9. Do you smoke?*

YesNo

If yes, how many cigarettes do you smoke a day?

10. Do you drink alcohol?*

YesNo

11. Do you take any drugs? *

YesNo

12. Do you have an illness or complaints which are not included on this sheet and you think it is important for us to know?*

YesNo

If yes, please explain

13. Have you got a pacemaker*

YesNo

14. FOR WOMEN: Are you pregnant?*

YesNo

15. G.P's Name*

Telephone*

Area CodePhone Number

Address

Please be aware that any illnesses or drug allergies you suffer from must be taken into consideration prior to dental treatment. For this reason, we must be well informed about your recent health issues and treatments to have an understanding of all aspects of your health. We ask you to inform us about any changes to the above given details at your next dental treatment.

I hereby declare that all of the above is true.

Date*

Date

Patient's signature*

NEW PATIENT - PERSONAL INFORMATION

PERSONAL INFORMATION - PLEASE PRINT YOUR DETAILS

IMAGE CONSENT

PRACTICE STATEMENT

HEALTH INFORMATION SHEET - PLEASE PRINT