• Patient Info

  • Today's Date*
     - -
  • Date of Birth*
     - -
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Format: (000) 000-0000.

  • Primary Dental Insurance

  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Secondary / Medical Insurance

  • Date of Birth*
     - -
  • Format: (000) 000-0000.

  • Emergency Contact

  • Format: (000) 000-0000.

  • Payment Terms

  • Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment.

    Some insurance companies pay fixed allowances for certain procedures while others pay a percentage of the charge. It is your responsibility to pay any deductible, coinsurance, or any balance not paid by your insurance.

    To control billing costs, payment is requested at the time services are rendered.

    The patient and/or responsible party agrees to pay:

    • Interest at 1½% per month
    • All collection costs
    • Reasonable attorney fees

    on balances more than 30 days past the date of service.

    To determine liability for payment and obtain reimbursement, I authorize disclosure of portions of my medical record.

    I assign all dental benefits to:

    Wladimir Gedeon, DDS

    This assignment remains in effect until revoked by me in writing.

    A photocopy of this assignment shall be considered as valid as the original.

    I understand that I am financially responsible for all charges whether or not paid by insurance.

    I authorize the practice to obtain a credit report if my account is referred for collections.

    I understand all procedures performed are medically necessary and waive any defense to the contrary.

    If paying by major credit card, a 3% service fee will be charged.

  • Date*
     - -

  • Medical History

  • Format: (000) 000-0000.
  • Date of Birth*
     - -

  • Medical Questions

  • When was your last physical examination?*
     - -
  • Format: (000) 000-0000.
  • Have you been hospitalized during the past two years?*
  • Do you have any allergies?*
  • Have you ever experienced excessive bleeding requiring special treatment?*

  • Do You Currently Suffer From Any of the Following?

  • Are you pregnant?
  • Medical conditions

  • Other Medical Conditions

  • Do you smoke?
  • Do you wear contact lenses?*
  • If you are having surgery today, have you eaten or drunk anything within the last six hours?*

  • I certify the above information is true and complete. I agree to notify the doctor of any changes to my medical history or medications.

  • Date*
     - -

  • Privacy Practice Consent

  • Our Notice of Privacy Practices explains how we may use and disclose your protected health information.

    You have the right to:

    • Review the Notice of Privacy Practices.
    • Request restrictions on disclosure (though the practice is not required to agree).
    • Revoke your consent in writing at any time.

    This consent complies with the Health Insurance Portability and Accountability Act (HIPAA) of 1996.

  • Authorized Individuals

  • Format: (000) 000-0000.
  • Format: (000) 000-0000.
  • Permission to Speak With Other Medical Professionals?*

  • Permission to Leave Detailed Voice Messages

  • Format: (000) 000-0000.
  • Phone number is:
  • Format: (000) 000-0000.
  • Phone number is:

  • Patient Rights

  • The patient understands:

    • They may refuse disclosure of protected health information for treatment, payment, or healthcare operations.
    • They have had the opportunity to review the Notice of Privacy Practices.
    • The practice reserves the right to change its privacy policies.
    • They may request restrictions on disclosure, though the practice is not obligated to agree.
    • Consent may be revoked in writing at any time.
    • Treatment may be conditioned upon signing this consent.
  • Date*
     - -
  • Should be Empty: