New Patient Form

Privacy Information

I have received this practice’s Notice of Privacy Practices written in plain language. The Notice provides in detail the uses and disclosures of my protected health information that may be used by this practice, my individual rights and the practice’s legal duties with respect to my protected health information. The Notice includes:

  • A statement that this practice is required by law to maintain the privacy of protected health information.
  • A statement that this practice is required to abide by the terms of the notice currently in effect.
  • Types of uses and disclosures that this practice is permitted to make for each of the following purposes: treatment, payment and health care operations.
  • A description of each of the other purposes for which this practice is permitted or required to use or disclose protected health information without my consent or authorization.
  • A description of uses or disclosures that are prohibited or materially limited by law.
  • A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization.
  • My individual rights with respect to protected health information and a brief description of how I may exercise these rights in relation to:
    • The right to complain to this practice and the Secretary of HHS if I believe my privacy rights have been violated, and that no retaliatory actions will be used against me in the event of such a complaint.
    • The right to request restrictions on certain uses and disclosures of my protected health information, and that this practice is not required to agree to a requested restriction.
    • The right to receive confidential communications of protected health information.
    • The right to inspect and copy protected health information.
    • The right to amend protected health information.
    • The right to receive an accounting of disclosures of protected health information.
    • The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request.

This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains. I understand that I can obtain this practice’s current Notice of Privacy Practices on request.

Patient Information
Emergency Information
Insurance Information
For Minors
Medical History
General Health
Anemia Tonsillitis/Adenitis
Hepatitis Tonsils Removed
Kidney Problems Adenoids Removed
AIDS/HIV+ Asthma
Rheumatic Fever Mouth Breathing
Heart Disease Speech/Hearing Problems
Heart Murmur High/Low Blood Pressure
Stroke Drug Sensitivity
Diabetes Radiation Treatment
Tuberculosis Neurelogical Problems
Endocrine Problems Venereal Disease
Epilepsy Pregnancy
Psychiatric Care Ulcer or Colitis
Cleft Lip/Palate Latex Allergy
Bone Disorders None
Dental Health
Head/Face Injuries Dental Injuries
Thumb/Finger Sucking Cheek/Lip/Nail Biting
Difficult Oral Surgery Clench/Grind Teeth
Click/Pop of Jaw Jaw Pain
Pain around Ear Frequent Headaches
Bleeding Gums Sensitive Teeth
Frequent Cold Sores Periodontal Treatment
Cigarette/Pipe Smoking None
Describe any current medical treatment including drugs taken, even though not listed above:
Has the patient ever been treated in an emergency room? If so, why?
Has the patient ever had any unfavorable reactions or allergic reactions to any medication? If so, describe:
Does the patient presently take any daily medication? If so, describe:
Is the patient currently under the care of a physician for a current condition? If so, describe:

Missed or frequently rescheduled appointments are the #1 cause of extending the total treatment time. They also may reduce the success of your treatment. Arriving late for appointments will not permit us to accomplish the treatment we had planned for that day. If you are late for an appointment, you will be rescheduled. If it is necessary to change an appointment we appreciate being notified as far in advance as possible or within 24 hours of your scheduled time.