www.commonsensefamilydentistry.com - Patient Information Form

Patient Information Form
Name*

First NameLast Name
Preferred Name
Date*

MonthDayYear
Date
Gender*
If "Other" Please Explain*
Marital Status
Date of Birth*

MonthDayYear
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Email*
example@example.com
YesNo
Employer Name
YesNo
Emergency Contact
Emergency Contact Name*
Relationship*
Phone Number*
Please enter a valid phone number.Format: (000) 000-0000.
Address*

Street Address

Street Address Line 2

CityState

Zip Code
Responsible Party Information
YesNo
If not please fill out the information below:
Name

First NameMiddle NameLast Name
Gender
Marital Status
Date of Birth

MonthDayYear
Mailing Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Name
YesNo

Insurance Information-all information refers to Insured Member
Name*
Date of Birth*

MonthDayYear
Social Security Number
Address

Street Address

Street Address Line 2

CityState

Zip Code
Home Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Work Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Cell Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Employer Name
Relationship to Patient
If "Other" Please Explain
YesNo
Insurance Company Name
Insurance Company Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
How did you hear about our office?
Insurance Authorization
Signature on File
1. I authorize the use of this form on all my insurance submissions.
2. I authorize release of information to all my insurance carriers.
3. I understand I am responsible for my bill, regardless of whether insurance pays or not.
4. I authorize my doctor to act as my agent in helping me to obtain payment form my insurance carriers. Any amount not paid by my insurance within 60 days of the service date will be paid by me.
5. I authorize payment of claims directly to my doctor.
6. I permit a copy of this authorization to be used in place of the original.
Consent for Treatment
1. I hereby authorize Dr. Stucki and his associates and staff to take x-rays, study models, photographs, and other diagnostic aids deemed appropriate by the doctor to make a thorough diagnosis of (Patients Name) dental needs.
2. Upon such diagnosis, I authorize Dr. Stucki and his associates to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care.
3. I agree to the use of anesthetics, sedatives, and other medication necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any complications.
4. I agree to be responsible for payment of all services rendered on my behalf or my that of my dependents. I understand that payment is due at the time of service unless other arrangements have been made. In the event payments are not received by agreed-upon dates, I agree to pay all costs of collection, including a 33.3% collection fee, attorney fees, court fees, and interest at the rate of 1.5% (18% APR) with a minimum of $5 and any late charges. If required, I also understand a check of my credit history may be made.
Patient's Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Parent/Responsible Party Signature

Clear
Relationship

Doctor's Painless Pledge
I pledge to dedicate myself to using the best techniques and technologies in my possession to Painlessly perform your dental treatment where ever possible.

Welcome to the world of Painless Dentistry. Painless Dentistry by definition is delivering an injection in such a manner that it reduces or eliminates pain. The method in which dental procedures are performed should reduce both anxiety and pain during and after treatment. While not every procedure can be painless, our office is dedicated to providing Painless Dentistry to the best of our abilities through proven techniques and available technology to reduce pain for the majority of dental procedures.

Many people interpret pressure or vibration as pain, this is a common misconception. Your dental team will explain what you can expect both during and after your dental procedure to help relieve any stress or anxiety in regard to your treatment.

This form is presented to every patient that Dr. Stucki sees to insure that they understand his commitment to providing treatment in an environment that is as Painless as possible. Each patient is encouraged to confer with the doctor or a team member to gain a more thorough understanding of each procedure before it is performed.

The American Academy of Painless Dentistry has collected documentation that Dr. Stucki has been able to perform Painless Dentistry for other patients. We trust he will be able to provide you with a similar experience.

We encourage you to let us know of your Painless experience by sending us a letter or an e-mail to the American Academy of Painless Dentistry to help us further document his Painless performance.
Mailing Address
American Academy of Painless Dentistry
E-mail Address
smile@drpainless.org
Patient's Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date

HIPAA Release Form
Name*

First NameLast Name
Date of Birth*

MonthDayYear
Release of Information-I authorize the release of information including the diagnosis, records, examination(s) rendered to me and claims information. This information may be released to: (please list none if you don't want your information shared).*
This Release of Information will remain in effect until terminated by me in writing.
MESSAGES
Please Call
If unable to reach me
Other method of reaching me
The best time to reach me is
(Day) between (Time)
Patient's Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date

Photograph and Publicity Release Form
Name*

First NameLast Name
I, {name} give D. Scott Stucki, DDS and Common Sense Family Dentistry permission to use my name, likeness, image, voice, and/or appearance as such may be embodied in any pictures, photos, video recordings, audiotapes, digital images, and the like, taken or made on behalf of D.Scott Stucki, DDS and Common Sense Family Dentistry activities. I agree that D. Scott Stucki, DDS and Common Sense Family Dentistry have complete ownership of such pictures, etc., including the entire copyright, and may use them for any purpose consistent with D. Scott Stucki, DDS and Common Sense Family Dentistry missions. These uses include, but are not limited to, illustrations, bulletins, exhibitions, videotapes, reprints, reproductions, publications, advertisements, social media and any promotional or educational materials in any medium now known or later developed, including the Internet. I acknowledge that I will not receive any compensation, etc for the use of such pictures, etc., and hereby release D. Scott Stucki, DDS and Common Sense Family Dentistry and its agents and assigns from any and all claims which arise out of or are in any way connected with such use.

I have read and understood this consent and release.

I give my consent to D. Scott Stucki, DDS and Common Sense Family Dentistry to use my name and likeness to promote D. Scott Stucki, DDS and Common Sense Family Dentistry program, its fiscal agent, and/or their activities.
Patient's Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Parent /Legal guardian (if under 18 years old)

Clear
Name

First NameLast Name
Date

MonthDayYear
Date

Notice of Privacy Practices
The information 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 the office of any changes.
Patient's Signature*

Clear
Name*

First NameLast Name
Date*

MonthDayYear
Date
Should be Empty:

Patient Information Form

Emergency Contact

Responsible Party Information

If not please fill out the information below:

Insurance Information-all information refers to Insured Member

Insurance Authorization

Signature on File

Consent for Treatment

Doctor's Painless Pledge

Mailing Address

E-mail Address

HIPAA Release Form

MESSAGES

The best time to reach me is

Photograph and Publicity Release Form

Notice of Privacy Practices