HP_CP_GP_Standardized

Patient Name*
Today's Date*

MonthDayYear
Date
Office Location:*
Date of Birth*

MonthDayYear
Date
Age
Cell Phone
Home Phone
Address*

Address

Street Address Line 2

CityState

Zip
Employer
Work Phone
Email*
example@example.com
Name of Spouse or Responsible Party*
Date of Birth*

MonthDayYear
Date
Cell Phone
Home Phone
SSN*
Address*

Address

Street Address Line 2

CityState

Zip
Employer
Work Phone
Email*
example@example.com
Primary Dental Insurance
Name of Insurer
Group Name
Name of Primary Person Covered by this Insurance
Date of Birth of Primary Person

MonthDayYear
Date
SSN
Secondary Dental Insurance
Name of Insurer
Group Name
Name of Primary Person Covered by this Insurance
Date of Birth of Primary Person

MonthDayYear
Date
SSN
Tertiary Dental Insurance
Name of Insurer
Group Name
Name of Primary Person Covered by this Insurance
Date of Birth of Primary Person

MonthDayYear
Date
SSN
Primary Care Provider Name
Phone
Preferred Pharmacy with Location
Referred By

Social MediaFriends/FamilyGoogleMailerBillboardDoctorDrive/Walk ByWord of Mouth
If you chose 'Doctor' as a referral, please list name below:
If referred by another source not listed, please list below:
Emergency Contact
Name*
Relationship*
Phone*

Payment/Insurance Policy
Payment Policy: Payment in full is due at the time of service. We accept all major credit cards, cash, or personal checks. We cannot guarantee any estimated coverage when billing insurance. Patients are responsible for determining if their insurance is contracted for the services that will be provided. Patients are responsible for all balances imposed by their insurance. You are ultimately responsible for any remaining amount unpaid by insurance. There will be a $50 service fee on any returned checks. All unpaid balances are subject to a 10% processing fee and will incur a 1.5% monthly finance charge. All delinquent balances must be paid prior to incurring any new charges. Patients are responsible for determining whether or not our providers are considered part of their insurer's network and will be responsible for all balances imposed by their insurance company. Any service overpaid will automatically be refunded to the patient's original payment method within 60 days. Checks will be issued within 60 days from the payment date for patients who made a cash payment.

Patient Signatures Release of Information to Insurers and Assignment of Benefits: To the extent permitted by law, I consent to my practices (or their designees) use and disclosure of my Protected Health Information to carry out payment activities in connection with my insurance claim. This information will be used exclusively to evaluate and administer claims for benefits. I further authorize and direct payment to my practice of the dental benefits otherwise payable to me.

Confirmation of Appointments: Appointments will be attempted to be confirmed before your scheduled appointment. You must confirm your appointment or your appointment will be canceled.

Missed or Broken Appointments: If you miss or break your appointment with less than 24 hours' notice, you will be subject to a $50-$100

Social Media/Photo Consent: I consent to use images taken of me/my child to showcase our extraordinary care. I understand that the office may post my images on any/all social media platforms and websites.

Consent to Treat: I give the dentists and dental hygienists permission to treat me in the dental office with exams, cleanings, x-rays, fillings, crowns and other dental procedures deemed advisable by our clinicians. While the vast majority of dental procedures cause little to no unwanted side effects, I understand there are risks to dental treatment, including but not limited to the following:
- Post-anesthetic injection complications can be psychologically and physically disabling, including bruising, limited opening, pain, dysfunction, as well as nerve damage. Needles can very rarely be separated inside the tissue and require surgery to remove.
- Aspiration of dental materials leading to emergency surgery.
- Damage to the jaw joint can occur in susceptible individuals, leading to pain and dysfunction of the jaw joint, which can be psychologically and physically disabling.
- Post-Surgical infections, swelling, pain, fever, and nerve damage, can occur. I understand that I must immediately notify my dentistifany of these conditions occur. I will seek emergency medical care if the infection appears to be more than minor.
- Dental treatment is highly effective and predictable; however, in some cases, treatment fails due to various reasons including, but not limited to, pre-existing conditions such as cracks in the teeth, severe decay and bone loss, patients not following up with timely appointments to complete treatment, health issues such as diabetes and complications of smoking, complex root canal systems leading to residual infections, diets high in sugar or soda, and your general health.
- Allergic reactions can happen in the dental office. In exceedingly rare instances, these reactions can be life-threatening.
- Post-cleaning sensitivity can occur. This is especially true if you have periodontal disease. If this happens, please contact the office, as we have topical medications to help.
Communication from Bluetree Brands: I consent to receive relevant communication from Bluetree brands and its affiliated partners.

We will do our absolute best to ensure you get the best care at our office. Please feel free to ask any questions regarding your treatment.

I have carefully read and given my consent to all the above sections on this form. I have had any questions regarding this form sufficiently answered to my satisfaction.
Patient Name*
Date*

MonthDayYear
Date
Guardian Name if Applicable
Signature of Patient/Guardian*

Clear

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
**You may refuse to sign this acknowledgment**

By signing below, I am stating that I have received a copy of this office's Notice of Privacy Practices:
Please Print Patient Name
Signature of Patient/Legal Guardian

Clear
Date

MonthDayYear
Date
The notice contains a patient's rights section describing your rights under the law. You certify by your signature that you have reviewed our notices before signing this consent. The terms of the notices are subject to change.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment, or healthcare operations. We are not required to agree with this restriction, but we shall honor this agreement if we do. The HIPAA (Health Insurance Portability and Accountability Act of 1996 Law) allows for the use of the information for treatment, payment, or healthcare operations. By signing this form, youconsent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such revocation will not be retroactive.

By submitting this form, I understand that:
- Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
- The practice reserves the right to change the privacy policy as the law allows.
- The practice has the right to restrict the use of the information, but the practice does not have to agree to those restrictions.
- The patient has the right to revoke this consent in writing at any time, and all full disclosures will cease.
- The practice may condition treatment receipt upon this consent's execution.
Our Notice of Privacy Practices provides information about how we may use or disclose protected health information. You may communicate with the following individuals relating to the patient's medical or payment information
Should be Empty:

	Select	Please Explain:
Taking Blood Thinners
Bleeding Disorder
Heart Attack - List Year.
High Blood Pressure
Heart Infection
Heart Problems/Defect
Born With A Heart Defect - Y or N?
Heart Valve Replacement
Heart Surgery
Aneurysm
Cardiac Pacemaker
Stroke
Cancer - (Active or History) - Type?
Cancer Meds/Chemo - When?
Radiation Therapy - Location:
HIV/AIDS
Hepatitis - Type?
Other Infectious Disease
Pregnant - Trimester?
Trying To Get Pregnant
Breast Feeding
Birth Control Hormones
Diabetes - Controlled? List Well, Fair, or Poor.
Kidney Disease
Dialysis
Liver Disease
Thyroid Disease
Glaucoma - Type?
Osteoporosis Medication - Name?
IV Drug Medications - Type?
Joint Replacement - Date of Surgery?
Tuberculosis - Cleared by Physician? Yes or No.
History of Drug Dependency?
Tobacco or Vape Use - Type?
Acid Reflux (GERD)
Asthma - Please list if Mild, Mod, or Severe.
Sinus Problems
Dental Anxiety - Please list if Mild, Mod, or Severe.
Mental Health Issues
Sensory Processing Issues
Fibromyalgia
Epilepsy or Convulsions
History of Long Term Steroid Treatments
Anaphylaxis or Severe Allergic Reaction
Autoimmune Disease - Please describe:
Immune System Issues - Please describe:
Breathing Problems or Emphysema
Other Condition Not Listed

	Please Select	Please Explain:
Dental Anxiety - Please list Mild, Mod, or Severe.
Impairment in Speech? Hearing? or Vision?
Tooth Pain or Discomfort
Orthodontic Treatment - List Braces or Invisalign
Sores or Lumps Around or in Your Mouth
Any Broken or Defective Teeth/Restorations
Periodontal Therapy
Bleeding Gums

	_________ Month(s) Ago	_________ Year(s) Ago
When was your last dental cleaning?
When was your last dental treatment?

Primary Dental Insurance

Secondary Dental Insurance

Tertiary Dental Insurance

Emergency Contact

Medical History

Dental History

Payment/Insurance Policy

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES