New Patient Forms – Ridge Road

Patient Information and Health History

Please take a few minutes to complete this confidential form so that we may better serve you.

Account Information (Primary Party responsible for payment)

First Name

Last Name

Address

City

State

Zip Code

Home Phone

Cell Phone

Work Phone

S.S.#

Date of Birth

Marital Status

Dental Insurance Plan

Insurance Co

Relationship to Patient

Type of Payment

Patient Information (Complete this section only if different from above)

First Name

Last Name

Address

City

State

ZIP Code

Home Phone

Cell Phone

Work Phone

Date of Birth

Gender

S.S.#

Relationship to Above

Patient Health History (Please be certain to answer every question)

Check if you have, or have had, any of the following:

Other

List Current Medication

1. Current Dental Problems:

2. How often do you visit a dentist?

3. When was your last visit?

4. What was done?

5. Physician’s Name & Address:

6. In case of emergency notify:

Their phone:

How did you learn about us?

Patient's Signature (Parent or Guardian if minor)

THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US,

We support your right to the privacy of your health information. We are required by applicable federal and state law to maintain the privacy of your health information, and to provide you this Notice about our privacy practices, our legal duties, and your rights concerning your health information.

We reserve the right to make changes in our privacy practices and the terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request. You may request a copy of our Notice at any time.

USES AND DISCLOSURES OF HEALTH INFORMATION

This notice allows us to use and disclose health information about you, or your minor child if you are a parent or guardian, as necessary for treatment, payment, and healthcare operations. We will limit the release of information necessary to assist in the specific need. Examples include:

Treatment: Schedules will be posted in our operatorics to assist in providing treatment. We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: Professional discretion is our goal. We may use and disclose your health information in connection with our healthcare operations, but will limit disclosure to the specific information needed. This includes coordination of treatment, quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.
Persons Involved in Care: In the event of your incapacity, or in an emergency circumstance, we will disclose health information based on a determination using our professional judgment that is directly relevant to the person's involvement in your healthcare or identification. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up prescriptions, medical supplies, x-rays, or other similar forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
Abuse or Neglect: We are required to disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety of others.
Contact Modes: We will use voicemail messages or answering machine messages, postcards, e-mails, or letters if we cannot reach you personally. If we cannot speak with you directly, we will limit the information divulged as much as possible, except in matters of medical.

PATIENT RIGHTS

Access: You have the right to look at or get copies of your health information, with limited exceptions. If you request copies, we will charge you per page, according to the limits set by state law. We will charge you a reasonable cost-based fee for expenses such as copies and staff time.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Amendments: Health information should be amended as necessary. You should advise us when changes in your health occur.

QUESTIONS AND COMPLAINTS

If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information, or in response to a request you made to amend or restrict the use or disclosure of your health information, you may complain to us, or may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint upon request. If you want more information about our privacy practices or have questions or concerns, please contact us.

Acceptance

I have received a copy of this office’s Notice of Privacy Practices. This documentation will be placed on file.

Add your Signature here: