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Byersdentalgroup.com


Welcome to our office. Our doctors and staff look forward to providing you with quality dental care
in a friendly and relaxed atmosphere. Your initial visit will include review of your medical and dental
history, taking necessary x-rays and an evaluation of your mouth. Our treatment recommendations
are based on your health needs. Thorough care is our foremost consideration and comprises not
only the eradication of existing dental disease, but its prevention in the future.
We want to clearly state our office policies to avoid any future confusion or
misunderstandings. Please carefully read these pages and sign where indicated to show your
understanding of, and agreement with, our policies.

Please help us to understand your primary dental concerns by checking all that apply:
Preventive care to preserve my teeth for life Routine maintenance to keep my teeth and gums healthy Cosmetic dentistry to improve the appearance of my smile Only the basic (limited) care offered by my insurance
Printed Name____________________________________________________ Date_____________________
Signature of Patient or Guardian________________________________________________________________

Notice of Privacy Practices Acknowledgement

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I
have certain rights to privacy regarding my protected health information. I understand that this
information can and will be used to:
Conduct, plan and direct my treatment and follow-up care among the multiple healthcare providers who may be involved in that treatment directly or indirectly Obtain payment from third party payers Conduct normal healthcare operations such as quality assessments and physician I give consent to the doctors’ or designated staff’s use and disclosure of any oral, written or electronic health records that are individually identifiable as mine for the purpose of carrying out my treatment, payment and health care operations. I understand that only the minimum amount of information necessary to provide quality care will be used or disclosed. I understand that I may request a copy of the full Notice of Privacy Practices from this office at any time. I am also aware that I can download a copy from this office’s website. Printed Name____________________________________________________ Date_____________________ Signature of Patient or Guardian________________________________________________________________ Treatment Consent

I hereby authorize the doctor or designated staff to take x-rays, study models, photographs and
other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of my dental
needs.
Upon such diagnosis, I authorize the doctor to perform all recommended treatment mutually agreed
upon by me and to employ such assistance as required to provide proper care.

I agree to the use of anesthetic, sedatives and other medication as necessary. I fully understand that
using anesthetic agents and other medications embodies certain risks. I understand that I can ask
for a complete recital of any possible complications.
Printed Name____________________________________________________ Date_____________________
Signature of Patient or Guardian________________________________________________________________
Truth in Lending

Payment is due in full the day services are rendered. We accept cash, checks, MasterCard, Visa,
Discover and American Express. We also accept Care Credit, an outside financing company, which
offers various no-interest payment plans. Brochures with more information about Care Credit are
available upon request. Returned checks and balances older than 90 days are subject to additional
collection charges, including interest of 1 ½% per month. We do not offer any in-office financing.
Patient is ultimately responsible for balance on account, regardless of insurance coverage.
Failure to provide us with 48 hour notice for all appointment changes can result in a $60 minimum
charge.
Printed Name____________________________________________________ Date_____________________
Signature of Patient or Guardian________________________________________________________________

Personal Information
Date________________________________________ Date of Birth___________________________________
Name_________________________________________________________________________________________
Mailing Address_______________________________________________________________________________ City________________________________________ State________________ Zip Code________________ Home Phone______________________________ Work Phone______________________________________ Cell Phone________________________________ Email____________________________________________ Male
Patient referrals are greatly appreciated. Who may we thank for referring you?
_____________________________________________________________________________________________
Primary Dental Insurance Information
Subscriber’s Name____________________________________________________________________________
Date of Birth_____________________ Member ID/Social Security Number________________________
Insurance Company Name____________________________________________________________________

Phone Number__________________________________ Group Number___________________________
Secondary Dental Insurance Information

Subscriber’s Name___________________________________________________________________________
Date of Birth____________________ Member ID/Social Security Number________________________
Insurance Company Name____________________________________________________________________
Phone Number__________________________________ Group Number__________________________

Medical Information
Emergency Contact________________________________________ Phone_______________________________
Physician_________________________________________________ Phone_______________________________
Are you currently under physician’s treatment for any issue? Yes
If yes, describe_____________________________________________________________________________ ___________________________________________________________________________________________ Are you allergic to, or had a reaction to: Penicillin Latex Local Anesthetic Codeine Tetracycline Pain Medication Other Please describe____________________________________________________________________________ ___________________________________________________________________________________________ Have you been told you need to take antibiotics (premed) prior to dental visits? Yes No If yes, why?________________________________________________________________________________ What did you take? _______________________________________________________________________ Are you taking, or have you ever taken, a bisphosphonate drug? Yes (Boniva, Fosamax, Aredia, Zometa, Didronel, Actonel, Skelid or other) Have you ever had a serious illness or major surgery? Yes No If yes, please describe ____________________________________________________________________
___________________________________________________________________________________________
Do you use tobacco products? Yes No

Women only:


Please list all medications (including over the counter, vitamins and herbs) and reason:

Medication/Dosage

Do you have, or have you ever had, any of the following:

Mitral Valve Prolapse Hepatitis/Liver Problems Frequent/Severe Headaches Rheumatic Fever Allergy Bleeding Problems Blood Transfusions Anemia Steroid Therapy (Cortisone/Hydrocortisone) Radiation Treatment to Head/Neck Do you have any health concerns/conditions not listed that could affect your dental treatment? Yes If yes, please explain: __________________________________________________________________________ ________________________________________________________________________________________________ Printed Name______________________________________________________ Date_____________________ Signature of Patient or Guardian___________________________________________________________________

Source: http://www.byersdentalgroup.com/New-Patient-Forms-1.pdf

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