Alpha Dental Designs
Relationship to Subscriber:
SelfSpouseChildOther
* Please present your insurance card to be photocopied for our records.
I consent to the diagnostic procedures and dental treatment performed by my dentist, and to the release of information concerning my (or my child’s) health care, advice, and treatment to another dentist, or for evaluation and administering any claims for insurance benefits. I consent to the direct payment of my insurance benefits to the practice and understand my insurance may pay less than the actual bill for services and that I am responsible for any services not paid or covered.
I consent to receiving HIPAA-compliant electronic communications, such as email and text messages regarding treatment, payment, etc. I understand there is no obligation to receive these electronic communications.
Are you currently under the care of a physician?
Have you ever had any serious illnesses or operations?
YesNo
Have you ever taken Bisphosphonates (IV or Oral)? If yes, please list type and dates taken
Have you ever had head or neck radiation therapy?
Are you taking any blood thinners? If yes, which one(s)
List all medications you are taking:
Are you allergic to:
PenicillinClindamycinSulfa DrugsCodeineLatex
Are you pregnant?
Nursing?
Taking Birth Control
Allergies, hay fever, sinusitis
Emphysema
Pacemaker
Anemia
Epilepsy
Respiratory disease
Arthritis, Rheumatism
Fainting
Rheumatic fever
Artificial heart valve(s)
Headaches
Shortness of breath
Artificial joint (s)
Heart Murmur
Sickle Cell Anemia
Asthma
Heart Problems
Sinus trouble
Bleeding abnormally with surgery
Hepatitis type
Stroke
Blood disease, clotting disorders
Herpes
Slow healing wounds
Cancer
High blood pressure
Swelling of ankles/feet
Chemical dependency
Immune deficiency
Thyroid problems
Chemotherapy
Jaundice
Tonsillitis
Circulatory problems
Kidney disease
Tuberculosis
Long term cortisone/steroid use
Low blood pressure
Tumor or growths
Cough, persistent
Mitral Valve prolapse
Ulcers
Diabetes
Osteoporosis/osteopenia
Venereal Disease
Have you had an allergic reaction to local or general anesthetics?
Have you ever had trouble with/from prior dental treatment?
In our dental practice, we respect the importance of your time and we work very hard to schedule appointments that accommodate the scheduling needs of all our patients. We want you to know that we make every effort to see you at your scheduled appointment time. We greatly appreciate that you notify us at least 48 business hours prior to your scheduled appointment time, if you must CANCEL or RESCHEDULE your appointment. Please also note that a cancellation fee may be charged for an appointment if the appointment is cancelled or rescheduled without at least 48 hours notice.
All payments/co-payments for services are due at the time dental treatment is provided. Every effort will be made to provide a treatment plan for services with estimated costs, so that you can be prepared for payment on your next visit. As a courtesy to our patients, if you have dental insurance, we will file your dental insurance claims and bill your dental insurance company for treatment you receive. However, in the event the insurance company does not pay the estimated portion of the bill, the balance will become the patient’s responsibility and will be billed directly to you.
I, hereby give Alpha Dental Designs, Dr. Vera Krupnov and any of the employees the right and permission to use and/or publish photographs of me for clinical purpose only. Release of Claims: I, hereby release and discharge Alpha Dental Designs, Dr. Vera Krupnov and all persons functioning under her permissions or authority from any legal or equitable claims.
Check on the following:
Yes, you may use my photos.No, please do not use my photos.
Signature of Patient or Guardian:
Date:
Our Notice of Privacy Practices provides information about how we may use and disclose protected health information (PHI) about you. We provide this form to comply with the Health Insurance Portability and Accountability Act (HIPAA). Please review the Notice of Privacy Practices thoroughly before signing this acknowledgement form. If terms of our Notice change, a revised copy will be made available to you.
By signing this form, you acknowledge that our practice may use and disclose PHI about you for treatment, payment and healthcare operations. You have the right to request that we restrict how PHI about you is used or disclosed for treatment, payment or healthcare operations.
We cannot discuss your health information with anyone other than yourself unless you authorize us to do so. Please list below names of the individuals you authorize our office to discuss care with.
I give you permission to share my health information with:
Consent to email or text for appointment reminders and other healthcare communication.
If you approve, we may contact you via email and/or text messaging to remind you of an appointment or provide general health reminders or information. I understand that once I have consented to receive communications via text or email, I still have the right to revoke the consent at any time.
The cell phone number I authorize to receive text messages for appointment reminders and
The cell phone number I authorize to receive email messages for appointment reminders and
I authorize all communications to the information provided on this form.
