New Patient Information Form

I certify that I have read and understand the questions above. I acknowledge that my questions have been answered to my satisfaction. I will not hold my dentist or any other members of his/her staff responsible for any errors that I have made in the completion of this form.

Adult/Guardian: I hereby consent to the treatment indicated on my examination form, including the use of any anesthetics, sedatives, or x-rays, as may be deemed necessary by the doctor.

Payment Agreement

I agree that I am responsible for all services rendered to the Patient that payment is due and payable to the Practice at the time services are rendered and that health, dental, and accident insurance policies are an arrangement between my insurance carrier and me. I agree to pay all deductibles and co-pays at the time of service (if I have dual insurance coverage, my co-pay or deductible will be based on the primary coverage). I understand that while the Practice will file claims with my insurance company on my behalf, I remain responsible to the Practice for what is not paid by my insurance company. I also understand that if the Practice cannot verify insurance benefits eligibility for me prior to treatment I will pay in full for the services at the time they are rendered. I understand that the Practice may charge: 1) a late fee if the payment on my account is not received by the due date; 2) an amount equal to $35.00, but not to exceed the maximum amount permitted by law for each returned check, and 3) a fee for each appointment that is missed/canceled without at least 24 hours advance notice. I agree to the extent permitted by law, that if my account balance is referred to any agency or attorney(s) for collection purposes, to pay reasonable attorney’s fees and any expenses or costs relating to the collection proceeding, including court costs. I understand that if treatment or care is suspended at any time by the patient, all fees for professional services rendered will be immediately due and payable. I authorize payment directly to the Practice.

I acknowledge having received a copy of the Practice's Notice of Privacy Practices. I agree that a photocopy of this authorization is as valid as the original.

I understand that the estimated insurance benefit is just that, an estimate, and I am personally
responsible for any balance not paid by insurance. Examples include, but are not limited to:

1. The treatment cost goes over the annual maximum insurance allowance.
2. The insurance company denies any of the treatment.
3. I am not eligible for insurance benefits.
4. I prevent or delay payment by not complying with requests for insurance information, forms, or signatures.
5. I do not complete my treatment and it results in non-payment by the insurance company.
6. Additional lab costs are incurred for any reason, including missed appointments.
7. I received my insurance check and did not sign it over to Complete Dental Studio.
8. I discontinue or am dropped from my insurance plan and this results in non-payment.
9. Insurance fails to pay for any reason.

I hereby authorize payment of my dental insurance benefits directly to Complete Dental Studio. I understand I am financially responsible for any charges not covered by this authorization. I hereby accept the recommended treatment plan and authorize release of any information related to this claim. I have read and understand my obligations with regard to the acceptance of my dental insurance as payment.

Our office strives to bring its patients state-of-the-art technology to provide you with the latest advancements in oral health. We have recently introduced the OralID screening device into our office. The OralID examination will allow us to visualize any oral mucosal abnormalities including cancer and dysplasia (precancer) before they can be detected with the naked eye. The procedure is quick, painless and no rinses or dyes are used.

Similar to other cancers, early detection of Oral Cancer is critical. Studies have shown that early detection of oral cancer with technologies like the OralID dramatically improves the survivability of the disease. If oral cancer is detected in its later stages, which typically occurs during a conventional oral cancer exam, the chance of survival is dramatically reduced.

Who is at Risk?

• Age – 17+ years
• Tobacco Use
• Alcohol Use
• HPV Infection

If you have any questions about risk factors, please feel free to talk to our team. We recommend all our patients be screened with the OralID annually to reduce the mortality of late-stage detection.

Your protected health information (i.e. individually identifiable information such as manes, date, phone/fax number, email, home address, social security numbers and demographic data) may be used or disclosed by used in one or more of the following aspects.

• To other health care providers in connection with our rendering orthodontic treatment to you (i.e. to determine the results of cleaning, surgery, etc.)
• To third party payors or spouses (i.e. insurance companies, administrators of flexible spending accounts etc..) to obtain payment of your account
• To certifying, licensing bodies in connection with obtaining certification, licensure of accreditation;
• Internally, to all staff members who have any role in your treatment;
• To other patients and third parties who may see or overhear incidental disclosures about your treatment, scheduling, etc.;
• To your family and close friends involved in your treatment; and/ or,
• We may contact you to provide appointments reminders of information about treatment alternatives or to the health-related benefits and services that may be of interest to you.
• Any other uses of disclosures of your protected health information will be made only after obtaining your written authorization, which you have the right to revoke,

Under the new privacy rules, you have the right to:

• Request restrictions on the use and disclosures of your protected health information;
• Request confidential communication of your protected health information;
• Inspect and obtain copies of your protected health information through asking us;
• Amend or modify your health information in certain circumstances;
• Receive and accounting of certain disclosures made by us of your protected health information;
• You may, file a complaint as to any violation by us of your privacy with us (by submitting inquires to the office manager at our office address) to the US secretary of health and human services (which must be filed within
  180 days of violation)

We have the following duties under the privacy rules:

• By law, to maintain the privacy of protected health information and to provide you with this notice setting forth our legal duties and privacy with respect to such information;
• To abide to the terms of out privacy notice that is currently in effect;
• To advise you of your rights to change the terms of the privacy notice and to make new notice provisions effective for all protected health information maintained by us, and that if we do so, we will provide you with a
  copy of the revised privacy notice.

Please note that we are not obligated to:

• Honor any request by you to restrict the use or disclosure of your protected health information;
• Amend your protected health information if, for example it is accurate and complete
• Provide an atmosphere that is totally free of the possibilities that your protected health information may be incidentally over hear by other patients and third parties.
  This privacy notice is effective as of the date of your signature. if you have any questions about the information
  in the notice, please ask for more information from the manger. Thank you

*Patient acknowledgement

I hereby acknowledge that I have received and reviewed a copy of this privacy notice

Thank you for filling out your Privacy Notice Form!

Please let us know who is eligible to receive your information on your behalf. These individuals will be the only ones who can receive any information. Example: Appointment Times/Dates, and Treatment information

Preferred Pharmacy Information