Cloud 9 Health History/HIPAA/Communication Authorization/Media Consent - Pure Header Image

PATIENT INFORMATION

:  
The following information is for a(n):*
Gender:*
Patient's Date of Birth*
Is texting permitted?*
Home Address:
Parents' Marital Status:
Marital Status:
Person Responsible for Account:

HIPAA Consent

This privacy notice is effective as of the date of your signature. If you have any questions about the information in this Notice, please ask for our Privacy Consent Person or direct your questions to this person at our office address.*

Authorization for Cell Phone and Email Use

I give my consent to the provider to use my cell phone for appointments, treatment information, insurance, account and billing information and special promotions. I understand that I can withdraw my consent at any time.

Choose all that apply:*
Certification:*

Photographic / Media / Social Media Consent

  • Without expectation of compensation or other remuneration, now or in the future, I hereby give my consent to the provider and its affiliates and agents, to use my image, video and photographic likeness and/or any interview statements from me in its publications, advertising or other media activities (including the Internet and Social Media sites).
  • I hereby consent to the collection and use of my personal images by photography or video recording.
  • I further acknowledge that the provider may use my image in media to promote the practice in the future.
  • I understand that no personal information, such as names, will be used in any publications unless express consent is given.
  • I also understand that my consent can be withdrawn at anytime in writing to the provider.
I have read the above statements and I give this consent voluntarily.*

DENTAL INSURANCE

Do you have Dental Insurance?*

[For patients with dental insurance who would prefer their Ins. Company to send payment to the office?]

I hereby authorize my insurance benefits to be paid directly to the provider. I realize that I am responsible to pay for any deductible amount(s), my co-insurance portion and for any non-covered services. I understand that I am financially responsible for any and all charges of dental treatment and incurred fees, whether or not paid by said insurance and I agree to pay such charges in full. I also hereby authorize the release of pertinent medical/dental information to the insurance carrier(s). This order will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.*
Do you have Secondary Insurance?*

PATIENT DENTAL HISTORY

Do you have a Dentist?*
Have there been any injuries to the face, mouth or teeth?*
Have you had or do you presently have any of the following habits?
Have you been informed of any missing or extra permanent teeth?*
Are you aware of sores, lumps or irritated areas in the mouth?*
Has an orthodontist been consulted previously?*
Have you had previous orthodontic treatment?*
Have you ever been treated for:*
Do you have bleeding gums?*
Are you concerned about the appearance of your teeth?*
Do you have any speech problems?*
Is there anything you would like to change about your smile?*
What aspect of dental treatment are you most concerned with?*

PATIENT MEDICAL HISTORY

Is your general health good at this time?*
Are you under the care of a physician at this time?*
Are you taking any medication?*
Do you have any allergies? (Penicillin, Sulfa, Latex, etc.)*
Have you ever had a serious illness or been hospitalized?*
Have you had your tonsils and/or adenoids removed?*
Have you ever been advised by your physician to take an antibiotic prior to any dental treatments?*
Do you have any special problems not listed?*
Do you use tobacco? (smoking or chewing)*
Have you recently noticed a growth spurt?*
Are you pregnant or considering pregnancy during the next 2 years?*
Are you currently taking medication for birth control?*
Are you nursing?*

DO YOU HAVE NOW, OR HAVE YOU EVER HAD ANY OF THE FOLLOWING?

(Please select all that apply)

Terms and Conditions

Office Personal Information Consent

We are committed to protecting the privacy of our patient's personal information and to utilizing all the personal information in a responsible and professional manner. This document summarizes some of the personal information that we collect, use and disclose personal information when permitted or requested by the law. 

We collect information from our patients such as name, home and work addresses, home and work telephone numbers, and email addresses (collectively referred to as 'Contact Information'). Contact information is collected and used for the following purposes: 

  • To open and update patient files. 
  • To invoice patients for dental services, process credit payments, or collect unpaid accounts. 
  • To process claims for payment or reimbursement from third party health benefit providers and insurance companies. 
  • To send patients informational material about our practice. 

Contact information is disclosed to third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment for all or part of the cost of dental treatment, or has asked us to submit a claim on the patient's behalf. 

Financial information may be collected in order to make arrangements for the payment of dental services. 

We collect information from our patients about their health history, their family history, physical condition, and dental treatments (collectively referred to as 'Medical Information'). Patients Medical Information is collected and used for the purpose of diagnosing dental conditions and providing dental treatment. 

Patients Medical Information is disclosed: 

  • To third party health benefit providers and insurance companies where the patient has submitted a claim for reimbursement or payment of all or part of the cost of dental treatment, or has asked us to submit a claim on the patients' behalf. 
  • To other dentists and dental specialists where those dentists have asked us, with the consent of patient, to provide a second opinion. 
  • To other dentist and dental specialist where those dentist have asked us, with consent of patient, to provide a second opinion. 
  • To other dentist and dental specialist, if the patients, with their consent, has been referred by us to the other health care professional for either a second opinion or treatment. 

If we are ever considering selling all or part of our dental practice, qualified potential purchases may be granted access as part of the due diligence process to patient information in order to verify information important to the potential sale. If this occurs, we will take steps to ensure that the prospective purchaser safeguards all personal information. 

Dentists are regulated by the Alberta Dental Association and Collage, and our facility is also regulated by the College of Physicians and Surgeons of Alberta, which may inspect our records and interview our staff as part of its regulatory activities in the public interest. 

*If patient is under 18 years of age, the consent must be acknowledged by a parent or guardian. 

I, the undersigned, have completed the health questionnaire and certify that the preceding information is true and correct. THIS OFFICE WILL NOT BE HELD RESPONSIBLE FOR ANY PROBLEMS ARISING OUT OF INADEQUATE INFORMATION. I grant authority to the Doctor and Staff to perform all procedures and treatments in my best interest. I authorize the provider to share treatment information with collaborating dentists and surgeons when appropriate. I authorize the provider to submit treatment information pertinent to this patient to the Insurance Company for billing purposes only. I understand that, when appropriate, Credit Bureau reports may be obtained.

Our practice may use your records for educational and promotional purposes. I know this is in the Consent form, but it allows us to use their photos, etc. for teaching purposes even if they do not start treatment.
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