• Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • Gender
  • Format: (000) 000-0000.
  • Can we text you?
  • Format: (000) 000-0000.

  • Communication Preferences

  • Please indicate the methods by which we may communicate with you. By checking a box below, you authorize our office to leave detailed messages that may include protected health information (PHI), such as appointment information, treatment recommendations, insurance, billing, and other information related to your dental care.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Dental Insurance

  • Do you have dental insurance?

  • *If YES, please provide us with your dental insurance information. You may bring this info to your appointment or upload the Front and Back of your insurance card below.

  • Policy Holder Information

    If the policy is in someone else's name (you are NOT the policy holder), please provide that information below.
  • Policy Holder Date of Birth
     - -
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
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  • Dental History

  • 1. Are you currently experiencing dental pain or discomfort?
  • 2. Are your teeth sensitive to cold, hot, sweets, or biting pressure?
  • 3. Are you aware of grinding or clenching your teeth?
  • 4. Do you have clicking, popping, or discomfort in your jaw?
  • 5. Do you wear any type of nightguard or retainers?
  • 7. Are you in active Orthodontic treatment?
  • 8. Do you wear partials or dentures?

  • Medical History

  • 1. Are you taking any medications, pills, or drugs?
  • 2. Have you had an Artificial Joint Replacement (including Hip, Knee, Shoulder, Ankle)?
  • 3. Have you had a Heart Valve Replacement?
  • Please select if you have/had any of the following:
  • Are you Allergic to any of the following?

  • To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform the dental office of any changes in medical status.

  • Date*
     / /
    2 digit month, 2 digit day, 4 digit year

  • Smile Analysis

  • 1. Are you self-conscious about your teeth or smile?
  • 2. When photographed, do you smile with your lips closed instead of flashing a full smile?
  • 3. Would you like to change anything about the appearance of your teeth or smile?
  • 4. Would you like your teeth to be whiter?
  • 5. Are any of your teeth yellow, stained, or somewhat discolored?
  • 6. Do you see any pitting or defects on the surfaces of your teeth?
  • 7. Do you have any gaps or spaces between your teeth?
  • 8. Are any of your teeth turned, crooked, or uneven?
  • 9. Are the edges of any teeth worn down, chipped, or uneven?
  • 10. Do any of your teeth appear too small, short, large, or long?
  • 11. Do you have any prior dental work that appears unnatural?
  • 12. Do you have any crowns or bridges that appear dark at the edge of your gums?
  • 13. Do you have any gray, black, or silver (mercury) fillings in your mouth?

  • Dental Records Release Form

  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Please forward the following information

  • I hereby give you permission to release all dental records to:

    Van Praag Cosmetic & Family Dentistry 

    11 Yorkshire Street, Suite 101
    Asheville, NC 28803
    828-378-1080
    office@pvpdds.com

  • Patient Rights:

    • I have the right to revoke this authorization at any time.
    • I may inspect or copy the protected health information to be disclosed as described in this document.
    • Revocation is not effective in cases where the information has already been disclosed but will be effective going forward.
    • Information used or disclosed as a result of this authorization may be subject to redisclosure by the recipient and may not longer be protected by federal or state law.
    • I have the right to refuse to sign this authorization and that my treatment will not be conditional on signing.
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Authorization to Release Protected Health Information

    This form allows you to authorize Van Praag Cosmetic & Family Dentistry to discuss your protected health information (PHI) with the individual(s) you designate below. If you do not wish to authorize anyone, please indicate that below. You may change or revoke this authorization at any time by notifying our office in writing.
  • Type a question

  • Authorized Individual #1

  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year

  • Authorized Individual #2

  • Date of Birth
     / /
    2 digit month, 2 digit day, 4 digit year
  • The above individual(s) may receive information regarding (check all that apply):
  • Date
     / /
    2 digit month, 2 digit day, 4 digit year

  • Practice Financial Policy

  • At Van Praag Cosmetic & Family Dentistry, our goal is to provide high-quality dental care with transparency and fairness. To maintain this effort, we ask that you review and sign the following statement prior to receiving treatment.

    Payment Policy

    Treatments completed in a single visit, such as cleanings, exams, and basic fillings, will follow standard payment arrangements, including insurance processing.

    Major restorative procedures requiring multiple visits, such as crowns, bridges, dentures, and implants, will require:

    • 50% of the total treatment fee due at the first appointment.
    • The remaining balance is due at the final appointment.
    • Please note: If payment is not made, your final appointment may be rescheduled.

    Insurance Information

    Your insurance is a contract between you and your insurance company. As a courtesy, our office will file your insurance claims on your behalf. Although we are not in network with any dental insurance providers, we are happy to work with patients who have out of network benefits. Please note:

    • Insurance estimates are not guarantees of payment.
    • Payment is due according to our financial policy regardless of insurance coverage.
    • Any remaining balance not covered by insurance is the patient’s responsibility.

    Our goal is to make your experience as seamless and stress-free as possible, and we are here to help you navigate your insurance benefits to maximize your coverage.

    Payment Methods

    We accept cash, check, debit/credit cards, and financing options such as Affirm and CareCredit. Please speak with our front desk for payment assistance or questions. We appreciate your understanding and cooperation. If you have any questions about this policy or your treatment estimate, please ask a member of our team – we are happy to review it with you.

    I HAVE READ AND UNDERSTAND THE FINANCIAL POLICY STATED ABOVE.

  • Date*
     - -
    2 digit month, 2 digit day, 4 digit year

  • Notice of Privacy Practices

  • This notice describes how your health information may be used and disclosed by Van Praag Cosmetic & Family Dentistry and how you can get access to this information. Please review it carefully.

    YOUR RIGHTS: When it comes to your health information you have certain rights. This section explains your rights.

    Upon written request, you may:

    • Ask to see or get an electronic or paper copy of your health record or other information we have about you. We may also provide a summary of your health information if requested. A reasonable, cost-based fee may apply. We will provide this information as soon as possible but no later than 30 days after receiving your request.
    • Ask us to correct your health information you believe is incorrect or incomplete. We may deny your request but will provide a written explanation within 60 days.
    • Request confidential communications. You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address. We will accommodate reasonable requests.
    • Ask us to restrict certain uses or disclosures of your health information for treatment, payment, or healthcare operations. We are not required to agree to the request and may deny it if it would affect your care.
    • Request restrictions involving out-of-pocket payments. If you pay for a service in full out-of-pocket and request that we not share that information with your health insurer for payment or operations, we will honor that request unless required by law to disclose it.
    • Request an accounting of disclosures. You may ask for a list of times we have shared your health information for reasons other than treatment, payment, healthcare operations, and certain other permitted disclosures. We will provide an accounting covering the previous six years. One accounting per year is free; additional requests may involve a reasonable cost-based fee.
    • Revoke an authorization. You may revoke any authorization to use or disclose your PHI at any time, in writing, except where action has already been taken in reliance on that authorization.

     You may also:

    • Choose someone to act on your behalf. If you have given someone medical power of attorney or they are your legal guardian, that person may exercise your rights and make decisions regarding your health information. We will require proof of this authority before taking action.
    • Receive a paper copy of this notice at any time, even if you have agreed to receive the notice electronically.
    • File a complaint if you believe your privacy rights have been violated. You may contact the US Department of Health and Human Services Office for Civil Rights at:

    200 Independence Ave, S.W.,
    Washington, DC 20201
    1-877-696-6775
    www.hhs.gov/ocr/privacy/hipaa/complaints

    • We will not retaliate against you for filing a complaint.

    OUR RESPONSIBILITIES: The law requires us to:

    • Maintain the privacy and security of your protected health information (PHI).
    • Notify you promptly if a breach occurs that may compromise the privacy or security of your information.
    • Follow the duties and privacy practices described in this notice and provide you with a copy.
    • Not use or disclose your information in ways not described in this notice unless you authorize us to do so in writing. If you change your mind, you may revoke that authorization in writing at any time.

    YOUR CHOICES: For certain health information, you can tell us your preferences regarding what we share. If you have a clear preference for how we share your information in the situations described below, please let us know.

    In these cases, you have both the right and choice to tell us to:

    • Share information with your family members, close friends, or others involved in your care or payment for care.
    • Share information in disaster relief situations.

    If you are unable to tell us your preference (for example, if you are unconscious), we may share your information if we believe it is in your best interest. We may also share your information when necessary to lessen a serious and imminent threat to health or safety.                                                                           

    In these following situations, we will not share your information without your written authorization:

    • Marketing purposes
    • Sale of your information
    • Most sharing of psychotherapy notes

    In the case of fundraising, we may contact you regarding fundraising efforts, but you have the right to opt out of receiving such communications.

    OUR USES AND DISCLOSURE: We typically use or share your health information in the following ways:

    • Treatment. We can use your health information and share it with other professionals involved in your care. For example, we may share information with another dentist or physician if you are referred for specialized treatment.
    • Payment. We can use and disclose your health information to bill and receive payment from health plans or other entities. For example, we may provide information to your insurance company so it will pay for services provided.
    • Health Care Operations. We can use and share your health information to run our practice, improve patient care, and contact you when necessary. For example, we may use information about you to manage treatment plans and services.
    • Appointment Reminders and Communications. We may contact you by telephone, voicemail, text message, email, or mail to remind you of appointments, provide treatment information, or discuss billing matters. If you prefer a specific method of communication, please notify our office.
    • Business Associates. We may share your health information with third-party service providers that perform services for our practice, such as billing companies, electronic health record providers, laboratories, and consultants. These entities are required by law and contract to protect the privacy and security of your information.

    OTHER USES AND DISCLOSURES: We are allowed or required to share your information in other ways that contribute to the public good or public health. These include:

    • Public health and safety, such as preventing disease, assisting with recalls, reporting adverse reactions to medications, and reporting suspected abuse, neglect, or domestic violence.
    • Compliance with law, such as providing information to the Department of Health and Human Services or other authorities when required by law.
    • Organ and tissue donation, such as sharing information with organ procurement organizations.
    • Medical examiners or funeral directors by providing information after death when necessary.
    • Workers’ compensation, law enforcement, and government requests, including activities for health oversight agencies and national security.
    • Legal proceedings, such as responding to court orders, subpoenas, or administrative requests.
    • Research, such as using or sharing health information for approved health research when required safeguards are in place.

    SPECIAL PROTECTIONS: Federal law provides an additional privacy protection for certain health information, including records related to substance use disorder diagnosis or treatment. Such information will not be disclosed without your written consent except as permitted by law under 42 CFR Part 2.

    CHANGES TO THIS NOTICE: We reserve the right to change the terms of this notice, and the revised notice will apply to all health information we maintain. The updated notice will be available upon request in our office and on our website.

    CONTACT INFORMATION: If you have any questions about this notice or our privacy practices, please contact our office.

  • Notice of Privacy Practices

  • The Notice of Privacy Practices explains how my protected health information may be used and disclosed. I understand that I may request a copy or decline to receive a copy.*
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