montgomerycountyperio.com - New Patient Form

WELCOME
We are pleased to welcome you as a new patient. In order to serve your needs effectively, we feel you should become acquainted with our goal and services.

We appreciate your concern about periodontal infection, the most prevalent systemic bacterial disease in the world. Before any treatment can begin, a diagnosis and evaluation are made by periodontal probing to detect bone loss, from x-ray interpretation, and through other diagnostic procedures. After the evaluation, you will be informed of the extent of your periodontal problems, advised of a reasonable and safe treatment plan to correct or modify these problems, and provided with an estimate of the time and cost.

The initial comprehensive evaluation may require more than one appointment depending on the severity of your disease, and no definitive treatment will be initiated until the full evaluation is complete. The fee for the initial examination and consultation is $145.00 payable the day of your visit. A full-mouth radiographic series of periodontal density is required of all patients. If such x-rays are not available from your referring doctor, we will take a series and the fee for this service will be $190.00.

Our commitment is to provide the highest quality periodontal treatment in a comforting and caring manner. We are dedicated to correcting, improving, and maintaining your overall health while making every effort to save your bone support and natural teeth.

All appointments are Monday- Friday, and we attempt to schedule appointments at a time that is mutually convenient as we realize the value of your time. Promptness on your part is greatly appreciated.

Please feel free to ask questions about your personal evaluation and treatment program. Thank you for coming to see us as we are here to help you.

Sincerely,

Miles A. Mason, DDS, MSD

PROFESSIONAL FEES
All patients are concerned about the cost of health care, and we would like you to know that we strive to hold down our professional fees and can continue to do so with your help.

FINANCIAL ARRANGEMENTS Fees for examinations and consultations, x-rays, maintenance visits, and emergency services are payable at the time professional services are rendered.
For periodontal treatment programs, fees are estimated based on the information available concerning actual bone damage at that time. Final fees can be determined only following corrective therapy to assess the actual bone destruction. Occasionally, additional charges may be incurred during periodontal therapy or surgery; such charges would be added to the balance due.

Please make arrangements for payment by selecting from among the following options:
- Full payment at time of service - 5% bookkeeping discount for payment before treatment is rendered.
- American Express, MasterCard, Visa, or Discover.
- If you have dental insurance - you pay 50% of the proposed treatment. If we are overpaid you will receive a refund check, if you have a balance due, we will bill you.
- Outside Financing - For those who would prefer an extended payment plan. We offer Care Credit @ 800-365-8295 or www.carecredit.com.
- Patients with non-traditional discount plans (i.e. Careington,
  Aetna Access, etc.) must pay their portion in full.
  in order to qualify for the applicable discount associated with the individual plan.
All accounts must be cleared in full within 60 days. Past due accounts will be reported to the credit bureau and turned over to a collection agency.

APPOINTMENT CANCELLATIONS Since our treatment appointments are lengthy, cancellations can be problematic. We understand emergencies do arise and there is no penalty for 48-hour notice at such a time. However, unless 48-hour notice of an unforeseen circumstance has been given, there is a $40 per hour charge.

Again, thank you for your trust and confidence. Please feel free to ask any questions of me or the staff. We are here to help you.

I have read and understand the above and wish to accept professional treatment.
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PERIODONTAL THERAPY CONSENT

For Oral Diagnosis and Periodontal Surgery
I, Name , have been informed that the purpose of periodontal therapy is to treat my periodontally diseased gum tissues, tooth roots, and supporting alveolar bone structures. This is my consent to periodontal surgical therapy, muco-gingival therapy to correct gum recession, curettage, or other oral surgery deemed necessary or advisable due to actual pathology including bone grafting or surgical extraction of hopeless teeth.

If sedative drugs have been prescribed for my safety and comfort during the procedure, I agree that I will arrange to be driven to and from the office and that I will not drive for the remainder of the day.

I also agree to the use of topical and local anesthetic, oral sedation, intravenous sedation (I.V.), or nitrous oxide analgesia (laughing gas) as safe and advisable as the doctor recommends. Possible risks of parenteral conscious sedation anesthesia, as with any type anesthesia, include cardiac arrest, brain injury, and death.

I am aware of the possible complications and post-operative risks of surgery, anesthesia, and therapeutic drug use. Complications could include, but are not limited to: swelling, discomfort or infection in the mouth or I.V. insertion site; restricted mouth opening; paresthesia (numbness) of the jaw or gum nerves; esthetic changes such as increased tooth length exposing crown margins and gum recession (shrinkage); temporary interference with phonetics (speech sounds); and sensitivity to hot or cold for days, weeks, or occasionally several months.

I also realize that having this therapy does not preclude the possibility that one or more teeth may eventually be lost. I further understand that if no treatment is rendered, my present periodontal condition will probably worsen over time resulting in permanent tooth loss.

No guarantee or assurance has been given to me that the proposed treatment will be successful to my complete satisfaction. Due to individual pathology and existing bone loss, there exists a small risk of failure, the possibility of relapse, the need for selective re-treatment, or the worsening of my present condition despite the best periodontal care.

I understand that long-term success depends on my long-term continued performance of excellent oral hygiene and daily plaque removal, flossing after each meal, and my availability for regular periodontal maintenance visits.
I further give my consent to the taking of photographs of my mouth during surgery and/or post-operative photographs for educational purposes in dental schools, scientific publications, or for lectures to colleagues or for the public interest.

I also realize that I am fully responsible for complete and prompt payment of my account when due regardless of the amount insurance may cover or should there be a delay in payment by my insurer.
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How would you like us to communicate with you?
Our dental office sends appointment reminders, information about treatment, payment and insurance, and other communications. Please tell us how you would like us to communicate with you.
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For Phone and Text Communications:

This form is optional. You are not required to sign this form, and you do not need to sign it to receive care in our dental office.
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I consent to the following: Montgomery County Periodontal Associates or its service provider may contact me to provide health care information such as appointment reminders and information about treatment, Dr. Mason calling you after surgery, payment, my account or insurance, using telephone equipment that may be capable of automatic dialing. Montgomery County Periodontal Associates may:

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Please call Montgomery County Periodontal Associates right away if you get a new telephone number

Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW DENTAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.
Our Responsibilities

By law, Montgomery County Periodontal Associates must:
- Maintain the privacy of your protected health information (PHI).
- Provide you this Notice describing our legal duties and privacy practices.
- Notify you if a breach occurs that may have compromised the privacy or security of your PHI.
- Follow the terms of this Notice currently in effect.
How We May Use and Disclose Your Information
We may use or disclose your PHI for the following purposes without your written authorization:
- Treatment: To provide, coordinate, or manage your dental care. Example: sharing radiographs and information with a dental specialist about your treatment.
- Payment: To obtain payment for services. Example: sending information to your dental insurance company.
- Healthcare Operations: For business activities that support our practice. Example: quality assessments, audits, staff training.
Other Permitted Uses & Disclosures
We may also use or disclose PHI without your authorization in these situations:
- Required by Law: To comply with federal, state, or local laws.
- Public Health: For disease control, product recalls, adverse events.
- Health Oversight: To government health agencies for oversight activities.
- Judicial & Administrative Proceedings: In response to valid subpoenas or court orders.
- Law Enforcement: For reporting certain injuries, locating suspects, or complying with law.
- Coroners, Medical Examiners, and Funeral Directors: As needed for duties.
- Organ and Tissue Donation: If you are an organ donor.
- Research: When approved by an institutional review board or privacy board.
- Serious Threats: To prevent or lessen a serious threat to health or safety.
- Specialized Government Functions: For military, national security, or correctional purposes.
- Workers’ Compensation: To comply with workers’ compensation laws.
- Fundraising Communications: We do not currently use your information for fundraising purposes. If we ever do, you have the right to opt out of receiving such communications.
- Business Associates: We may disclose your information to business associates who perform services on our behalf (e.g., billing services, IT support). They are required to protect your information.
- Legal and Regulatory Requirements: We may disclose your information when required by law, including for public health activities, audits, investigations, or law enforcement purposes as permitted by HIPAA.
Uses & Disclosures Requiring Your Authorization
We must obtain your written authorization before using or disclosing your PHI for:
- Marketing communications not permitted by law.
- Sale of your PHI.
- If you give authorization, you may revoke it at any time in writing.
- Substance Use Disorder (SUD) Information: If we maintain records related to substance use disorder treatment that are subject to 42 CFR Part 2, those records receive special federal protections. Such information will not be used or disclosed without your specific authorization, except as permitted or required by law.
Your Rights Regarding Your PHI
You have the right to:
- Get a copy of your health records
- Request corrections to your health records
- Request confidential communications
- Ask us to limit what we use or share
- Get a list of disclosures
- Get a copy of this Notice
- Choose someone to act for you
- File a complaint if you believe your privacy rights have been violated
We will not retaliate against you for filing a complaint.

Your Choices
For certain information, you can tell us your choices about what we share, including:
- Sharing information with family or friends involved in your care
- Leaving messages with appointment information
If you have a clear preference, we will follow your instructions unless required otherwise by law.

Breach Notification
If a breach occurs that compromises the privacy or security of your PHI, Montgomery County Periodontal Associates will notify you without unreasonable delay and no later than 60 days after discovery of the breach.

Contact Information
If you have questions, requests, or complaints about this Notice or your privacy rights, contact: Montgomery County Periodontal Associates, HIPAA Privacy Officer: Miles A. Mason, DDS, MSD, Address: 1001 Medical Plaza Drive, Suite 110, The Woodlands, Texas 77380, Phone: (281) 363-2009

If you are not satisfied with the manner in which this office handles a complaint, you may submit a formal complaint to: U.S. Department of Health and Human Services Office for Civil Rights, 200 Independence Avenue, S.W., Washington, D.C. 20201, Voice Phone (toll-free): 1 (800) 368-1019 | TDD (toll-free): 1 (800) 537-7697 Email: OCRMail@hhs.gov. You will not be penalized in any way for filing a complaint.

Changes to This Notice
We reserve the right to change our privacy practices and this Notice. Updates will apply to all PHI we maintain. Revised notices will be posted in our office and on our website, if applicable, and available upon request.

Effective Date: 01/19/2026

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

*You May Refuse to Sign This Acknowledgement*
I, (parent of, if a minor) , have received a copy of this office's Notice of Privacy Practices.
Please Print Name Of Patient
Signature

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I, Name , will allow the above named entity to disclose my health information to:
List Names and relationship below
Should be Empty:

	Yes	No
Are your teeth sensitive to hot or cold?
Do you awaken with sore jaws?
Do you clench or grind your teeth?
Can you chew evenly on both sides?
Have you noticed your bite changing?
Have you noticed spaces developing between your teeth?
Have you ever had a gum abscess?
Have you had previous gum trouble?
Are you satisfied with the way your teeth or gums look?
Do you want to save your teeth, if possible?
Have you ever had orthodontic treatment (braces)?
Do you notice popping, clicking or soreness in the joints just in front of your ears (TMJ)?
Have you ever had complications during or after a dental procedure?
Do you feel your present oral hygiene is effective in cleaning your mouth?
Do you smoke or use products containing nicotine?
Do you drink 6-8 glasses of water daily?

WELCOME

PROFESSIONAL FEES

PATIENT INFORMATION

MEDICAL HISTORY

DENTAL HISTORY

PERIODONTAL THERAPY CONSENT

How would you like us to communicate with you?

Notice of Privacy Practices

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES