Patient Sign-in

Patient Registration Form

Patient Sign-in
New patient Registration
Medical History
Medical history
Dental History
Dental history

Patient Registration( * mandatory to fill )

Is the Patient Under 18(Minor)?
Yes
No

Guardian Information

How do we contact you?( * mandatory to fill )

Who do we contact in case of an emergency?( * mandatory to fill )

Please select below

Are You Married?
Yes No
Are You Employed?
Yes No
Do You Have Primary Insurance?
Yes No
Do You Have Secondary Insurance?
Yes No
I have read the above choices

Professional Information

Spouse Information( * mandatory to fill )

Primary Insurance Information( * mandatory to fill )

POLICY HOLDER : SELF OTHER
Dental Coverage: Yes No Unknown
Medical Coverage: Yes No Unknown
Orthodontic Coverage: Yes No Unknown
SIGNATURE
 
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Secondary Insurance Information( * mandatory to fill )

POLICY HOLDER : SELF OTHER
Dental Coverage: Yes No Unknown
Medical Coverage: Yes No Unknown
Orthodontic Coverage: Yes No Unknown
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Responsible Person for the Account( * mandatory to fill )

SELF OTHER

Medical History

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

(All questions are required * )

Are you under a physicians care now?
Yes
No
Have you ever had a serious head or neck injury?
Yes
No
Are you taking any medication, pills or drugs?
Yes
No
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Yes
No
Do you take, or have you taken, Phen-fen or Redux?
Yes
No
Have you ever been hospitalized or had a major operation?
Yes
No
Are you on a special diet?
Yes
No
Do you use tobacco?
Yes
No
I have answered all the above questions

Medical History

Are you a woman?
Yes
No
Are you allergic to any of the following?
Do you use controlled substances?
Yes
No
I have answered all the above questions

Medical History

Do you or have you experienced the following?

AIDS/HIV Positive
Yes
No
Alzheimers disease
Yes
No
Anaphylaxis
Yes
No
Anemia
Yes
No
Angina
Yes
No
Arthritis/Gout
Yes
No
Artificial Heart Valves
Yes
No
Artificial Bones/Joints
Yes
No
Asthma
Yes
No
Blood Disease
Yes
No
Blood Transfusion
Yes
No
Breathing Problems
Yes
No
Bruise Easily
Yes
No
Cancer
Yes
No
Chemotheropy
Yes
No
Chest Pain
Yes
No
Cold sores / Fever blisters
Yes
No
Congenital heart disorder
Yes
No
Convulsion
Yes
No
Cortisone medicine
Yes
No
Diabetes
Yes
No
Difficulty Breathing
Yes
No
Drug Addiction
Yes
No
Easily Winded
Yes
No
Emphysema
Yes
No
Epilepsy or Seizures
Yes
No
Excessive Bleeding
Yes
No
Excessive Thirst
Yes
No
Fainting spells / Dizziness
Yes
No
Frequent Cough
Yes
No
Frequent Diarrhea
Yes
No
Frequent Headaches
Yes
No
Genital Herpes
Yes
No
Glaucoma
Yes
No
Hay Fever
Yes
No
Heart Attack / Failure
Yes
No
Heart Murmer
Yes
No
Heart Pacemaker
Yes
No
Heart Trouble / Desease
Yes
No
Hemophilea
Yes
No
Hepatitis A
Yes
No
Hepatitis B or C
Yes
No
Herpes
Yes
No
High Blood Pressure
Yes
No
High Cholesterol
Yes
No
Hives or Rash
Yes
No
Hypoglycemia
Yes
No
Irregular Heartbeat
Yes
No
Kidney Problem
Yes
No
Leukemia
Yes
No
Liver Disease
Yes
No
Low Blood Pressure
Yes
No
Lung diseases
Yes
No
Mitral Value prolapse
Yes
No
Osteoporosis
Yes
No
Pain in Jaw Joints
Yes
No
Parathyroid Disease
Yes
No
Psychiatric Care
Yes
No
Radiation Treatments
Yes
No
Recent Weight Loss
Yes
No
Renal Dialysis
Yes
No
Rheumatic Fever
Yes
No
Rheumatism
Yes
No
Scarlet Fever
Yes
No
Shingles
Yes
No
Sickle Cell Disease
Yes
No
Sinus Trouble
Yes
No
Spina Bifida
Yes
No
Stomach/Intestinal Disease
Yes
No
Stroke
Yes
No
Swelling of Limbs
Yes
No
Thyroid Disease
Yes
No
Tonsillitis
Yes
No
Tuberculosis
Yes
No
Tumors or Growths
Yes
No
Ulcers
Yes
No
Venereal Disease
Yes
No
Yellow Jaundice
Yes
No
Have you ever had serious illnesses not listed?
Yes
No
I have answered all the above questions

What is the reason for your visit?
Are you currently in pain?
Yes
No
Do you require antibiotics before dental treatment?
Yes
No
Have you experienced problems associated with any previous dental work?
Yes
No
Do you now or have you ever experienced pain/ discomfort in your jaw joints (TMJ/TMD)?
Yes
No
Do you floss daily?
Yes
No
Do you use anything in addition to your brush and floss ?
Yes
No
Would you like whiter teeth?
Yes
No
Do your gums ever Itch?
Yes
No
Do you brush daily?
Yes
No
Would you like fresher breath?
Yes
No

Do your gums ever bleed?
Yes
No
Have you ever had Periodontal disease?
Yes
No
Do you have mobility in teeth ?
Yes
No
Do you still have wisdom teeth?
Yes
No
Your current dental health is
Good
Fair
Poor
Type of bristles on your toothbrush?
Hard
Medium
Soft
Are Your Teeth Sensitive to?
Heat
Cold
Other
Previous Dental Practice name?
Last visit to a Dental Office?
Are you happy with the way your smile looks?
Yes
No

Treatment Authorization

The information on this page is correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medication as indicated. I certify to the above statements regarding my medical condition.

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PRACTICE AGREEMENT

INFORMATION ABOUT YOUR DENTAL TREATMENT

The purpose of the following sections are to inform you of the procedures that we routinely perform here, to emphasize the importance of your role and cooperation in achieving a high level of oral health and beauty, and to point out the potential risks and inconveniences that may be encountered before, during and after treatment.

DESCRIPTIONS OF CERTAIN DENTAL PROCEDURES

Your dental treatment may involve one or a combination of the following procedures that are summarized below.
Examinations & Hygiene Cleanings: The initial examination and hygienic cleaning are intended in part to evaluate and make recommendations regarding the health and appearance of your teeth and gums. The dental exam, hygienic cleaning, and any basic restorative (e.g., fillings) or gingival therapy may involve the touching, scaling, or periodontal probing of your teeth and oral tissues. Other or subsequent hygienic procedures (periodontal scaling, root planning, etc.) may be indicated and performed as well depending on your condition. These procedures are designed to remove plaque or calculus from your teeth and help maintain or restore the health of your gums.
A Bridge is a replacement made for missing teeth. It is usually composed out of porcelain or porcelain fused to a harder substance like metal, which is bonded to adjacent teeth. These abutment teeth may require some reduction or crowning in order to support the teeth being replaced.
Crowns, Veneers, and other porcelain restorations and enhancements are designed to be life-like looking tooth restorations made out of porcelain or porcelain plus other materials. A crown usually covers the entire tooth structure (although there are 3/4 crowns and other variations). Typically, more tooth structure is removed to prepare for a crown placement than for a veneer (which may entail zero, minimal or significant tooth reduction, depending on the circumstances). Crowns may be recommended for teeth requiring additional support due to a loss of healthy tooth structure. Veneers primarily cover the front of the teeth, although some varieties also have porcelain on the backside of teeth. While the porcelain enhancements are being fabricated, you will have temporary crowns or veneers, which are not intended to be permanent and are easier to remove or pop off.
Fillings or Bonding are terms that are commonly used to refer to the placement of composite resins or other appropriate materials in cavities or on teeth. Bonding can be used to make a tooth colored filling for small cavities and repair broken or chipped tooth surfaces. It can also be used to close spaces between teeth. We have not placed amalgam fillings (sometimes called silver or mercury fillings) in over a decade because we believe that there are more desirable materials such as tooth colored composites and porcelain. Although some people have had amalgams for many years, we do usually remove amalgam fillings at the patients’ request. We want to make you aware that amalgam suppliers report that after placement or removal of amalgam fillings, there can be a slight, but measurable increase in mercury in your blood and/or urine.
Inlays or Onlays may be the recommended treatment when teeth have had decay or are broken down but retain enough healthy tooth structure to allow for restoration of certain voids in the tooth structure. The tooth is prepared much like a normal filling. The restoration material is custom fabricated out of composite resins, porcelain, or metal, and then bonded into the void.
Whitening is performed by applying a peroxide gel to the teeth. This can either be done in our office with an accelerated method or through a take home system. The peroxide reacts with the tooth structure to safely whiten the teeth. Porcelain or composite restorations will not whiten with peroxide whitening systems. At least one recent study has indicated that mercury from amalgam fillings can be released by prolonged exposure to peroxide based whitening gels.
Tooth Contouring is the reshaping of existing tooth structure by removing small amounts of enamel, usually around the edges. We give particular attention to the edges of the upper and lower front six teeth, which may be reshaped to create a more aesthetic result.
Gum Contouring is the reshaping of the gum tissue, which is many times done to give a more symmetrical appearance. This is usually done with a laser or electrosurge. In the hands of an experienced cosmetic dentist, it is a relatively simple, but dramatic procedure. Most patients report that for a day or so afterwards, it feels somewhat similar to a pizza burn when you eat pizza that’s too hot.
Root Canal Therapy can be indicated anytime that a tooth receives trauma or has dental work performed on it. In general, the more trauma or amount of work, the higher the risk is that a root canal will be needed. This therapy consists of removing the damaged or infected nerve in the tooth and replacing it with a sterile material. If there are existing restorations in place, this procedure can many times be performed by accessing the tooth through an access hole in the restoration and then repairing it without destroying the restoration, although destruction of the existing restoration is a risk as well. The Practice attempts to predict and notify you in advance of the likelihood of root canal therapy depending on your procedure, however, all people are different and the human body can react in a myriad of unpredictable ways. Thus, it is difficult or impossible to make accurate predictions of this sort in the vast majority of cases. Therefore, regardless of cause, should you require subsequent root canal therapy or restorative work (whether obtained here or at another office), which has not been paid for as part of your Treatment Plan, you agree to be responsible for those costs.
Local Anesthetic of various types may be used to block certain nerve impulses and numb the oral tissues before certain dental treatments. These are administered by injections to prepare for a number of both simple and complex dental and periodontal procedures.
Nitrous Oxide is sometimes called "laughing gas" and can result in feelings of relaxation, a reduced sense of fear or anxiety, increased tolerance to pain or discomfort, an altered perception of time, a tingling sensation, especially in fingers and toes, giddiness or light headedness, nausea, vomiting, incontinence, hallucinations or dreams. While the use of nitrous oxide is safe and effective for most people, it is not recommended for use on all patients. If you have any of the following conditions, you may not be a good candidate for the use of nitrous oxide: chronic obstructive pulmonary disease (emphysema), upper respiratory or throat infections, any acute respiratory conditions such as cold, flu, or sinus infection, claustrophobia, compulsive personality, taking any psychiatric mood altering drug, bowel obstructions, middle ear disturbances or pregnancy. Please notify the Practice doctor if you have any of these conditions and we will discuss other options that may be available.

ADDITIONAL TREATMENT INFORMATION

Specific Results Are Not Guaranteed
The dental procedures described above have a very high degree of success at our Practice. The human body, however, reacts differently to different dental treatments depending on a wide variety of factors. Each individual is different and the exact result for each specific case is difficult if not impossible to guarantee. Thus, as with any branch of medicine or dentistry, our treatment carries with it no guarantee of specific results. There are many variables that affect how long restorations, whitening, or other dental treatments can be expected to last and how the teeth and gums will react, including but are not necessarily limited to, general health, maintenance of good oral hygiene, regular dental checkups, etc. No matter how well done, chipping, breaking or loosening of dental work can occur. No guarantees can be made or assumed regarding the results or longevity of restorations, whitening, or other dental treatments.If you are provided a computer generated imaging of your smile, you understand that this is an artificial mechanism to serve as a basis for a discussion of treatment, and in no way provides a warranty or representation of specific results.
Alternative Treatments & Providers There is usually more than one way of doing things and there may be alternative treatments to what the Practice recommends for you, which may include, but are not necessarily limited to one or more various combinations of veneers, crowns, bonding, onlays, inlays, whitening, contouring of teeth or gums, bridges, dentures, extractions, root canal therapy, fillings, orthodontics, non-surgical therapy, surgical cuterage or cleaning, tooth extractions, implant treatments, as well as a variety of other dental treatments. All dental treatments have risks, so please make sure you have had an opportunity to ask about these alternatives and have them explained to your satisfaction. In addition, the dental treatments in our office are typically, but not always, performed by a general dentist. Another option is for you to have some of the above treatments done by one or more specialists (e.g., orthodontist, endodontist, oral surgeon, etc.). After hearing general descriptions of alternative treatments, if you would like a referral to any dental specialist, let us know and we will be happy to provide a referral. If you do not ask for a referral and proceed with the treatment, this will be considered by us to mean you have declined our offer for a referral.
Non-Treatment Option
One option is to have no treatment performed. This alternative may entail a number of actual or potential risks, each of which are difficult or impossible to quantify or predict for specific cases. Some of the risks of non-treatment may include, but are not necessarily limited to, exacerbation of any existing symptoms, deterioration of aesthetics or function of your teeth, improper biting, tooth, head and/or neck pain, fracturing of teeth, discoloration or staining of your teeth, rotation or movement of teeth, TMJ complications; additional wear of your teeth to the point they are not candidates for reconstruction, loss of teeth, bite problems, poor chewing, loosening of teeth, need for dentures, gum recession, bad breath, inability to perform adequate oral hygiene, abscesses or infection, pain, tooth sensitivity, tooth movements, worsening periodontal condition, deeper pockets, and other oral health problems.
Risks and Inconveniences
Inherent in your treatment plan (as well as with many similar or other dental procedures) are certain actual and potential risks and inconveniences, which vary based on individual circumstances and variations in teeth and gums. These risks and inconveniences may last for a short or an indefinable length of time.
General dental inconveniences and risks include, but are not necessarily limited to, bruising; discoloration; recession; abscesses; the need to repeat all or part of the procedure for known or unknown reasons; exposure of crown margins or edges; lisping; speech impediments or speaking difficulties; infections, virus; stretching of the mouth resulting in cracked corners; tooth mobility; oral surgery; food impaction; root staining; oral opening restrictions; tissue sloughing; the onset of or continued periodontal disease; root canal therapy; numbness of lip, chin, and gums; dental neuropathy; gagging; numbness; joint pain/disorder; accidental nicks or cuts from dental instruments or needle sticks to the body; chipping, breaking or fillings in other teeth; other tissues; loosening of the temporary or permanent restorations; tempromandibular joint (jaw joint) problems; nausea; bone or tooth fracture; adverse reaction to drugs, medications, and/or anesthetic (including nitrous oxide); dyspepsia; gum hemorrhage; mouth ulceration; nausea; tongue edemas; tooth disorder; varying psychological reactions; dental work that does not match the color of surrounding teeth or dental work; trapping of saliva or food; loss of surface shine from restorations; ledges; or local tissue necrosis.
The most common risks include, but are not necessarily limited to, swelling; tooth sensitivity; bleeding; gum irritation; gum, bone or teeth inflammation; stiffness of facial muscles; temporary numbness or tingling in the lip, tongue, teeth, gums, chin, cheek or jaw area; changes in occlusion; need for a night guard; permanent reduction of tooth structure; a need for you to modify the frequency or methodology of your home hygiene care (e.g., brushing and flossing to adequately go around corners, edges, etc.); or wearing temporary teeth for an undefined period of time as well as the general dental inconveniences and risks set forth above.
The more remote general dental risks include, but are not necessarily limited to, loss of teeth; implant rejections; permanent numbness or tingling in the lip, tongue, teeth, gums, chin, cheek or jaw area; severe pain; permanent or temporary injuries to the nerves of the tongue, jaw, chin and lips, including lingual nerve injury (tongue) and inferior alveolar nerve damage (lips, chin and jaw), permanent or temporary numbness or loss of taste sensation; permanent or temporary structural injuries to the tongue, jaw, chin or lips; parasthesia; sutures, accidentally swallowing or aspirating restorations, materials or dental tools, changes in facial appearance, referred pain to the ear, neck, jaw or head, allergic reaction, delayed healing, sinus complications, constipation, diarrhea, vomiting; aspiration of vomit; systemic toxicity, respiratory distress, heart failure, or death. There may be additional unknown or unlisted risks at this time, but that could manifest at a later time. You understand that your condition may be the same, better or worse after treatment. If previously placed dental restorations are in place on teeth, your treatment may entail additional alteration of tooth structure to properly prepare these teeth for new restorations, and/or other unknown or unspecified problems or risks, which the Practice may or may not have encountered, and which are difficult or impossible to predict or quantify in advance.

YOUR OBLIGATIONS

Cooperation
Successful dental treatment is a team effort involving you as the patient, the doctors and our team. Without cooperation, successful treatment planning, achieving optimal results and maintaining the treatment results are difficult or impossible and the results may be disappointing to everyone.
Scheduled Appointments
In order to serve our patients better, we strive to operate a professional, efficient dental practice. We attempt to reserve appropriate blocks of time for each of our patients so that the procedures may be completed with close attention to detail and with as few interruptions as possible. Missed appointments have a negative effect on our ability to maintain the level of service you and other patients deserve. While we are aware that circumstances may arise which interfere with set appointments, we require two business days notice for an appointment of 2 hours or less and one week notice for entire morning appointmentsso that we may attempt to contact other patients awaiting time for treatment. Failure to provide this notice may result in a missed appointment fee which is, not intended as a penalty, but as a reasonable estimate of the time and expense incurred by the Practice in attempting to fill such a cancellation or loss of deposit.

Financial Obligations
You have full responsibility for payment of the dental services that you or your dependents receive here. Fees are due and payable in full at or before the time services are rendered. A 1.5% finance charge (18% annually) will be added to any balance over 30 days past due. In the event of your failure to pay amounts owed when due, you agree to pay for collection costs and reasonable attorneys fees as may be incurred for collection. Any dispute arising out of the Practice’s services or collection are subject to the Federal Arbitration Act and at the Practice’s sole option, will be submitted to binding arbitration with the American Arbitration Association in Atlanta.

Providing Timely Information & Authorization for Signature on File
To process insurance documents, claims and related matters, you authorize the Practice to affix your signature and name to claims or documents related to insurance, claims or health benefits due to you. A photocopy of this form will act as an original. The Practice may disclose information provided by me or obtained during the course of my treatment for treatment, payment, or healthcare operations, including disclosure to laboratories, other dental offices, or professionals involved in my care, and to my insurance providers. As part of your treatment, you authorize the Practice to take radiographs (x-rays), study models, provide injections, take photographs, and give and perform any other diagnostic tests and aids deemed appropriate by the Practice to evaluate your condition and to generate my recommendations, for professional or educational purposes and for any other use as contemplated or set forth in the Practice’s current Notice of Privacy Policies, which isincorporated herein by reference.

Maintenance Obligations
For successful treatment results and to lessen the risks of complication, you agree to comply with your individualized maintenance program and keep excellent home oral hygiene. It is typical to need follow-up visits for occlusal or other adjustments after treatment. You agree to notify the Practice at the soonest possible moment in the event that you experience pain, discomfort or any other problem that you believe may be related to treatment in our office. Nothing in this form extends the applicable statutes of repose or limitations for dental services. You agree to keep your follow-up appointments and to follow recommended treatments as well as follow other precautions and recommendations that may be provided as part of your pre-op or post-operative instructions.

YOUR CONSENT

The information I have provided on this form is accurate and complete to the best of my knowledge, information, and belief. I will notify the Practice at the soonest practical moment of any changes in the information I have provided. In consideration of being accepted as a patient of the Practice, I agree to abide by the terms and conditions of this Patient Application & Practice Agreement.

By signing below, I acknowledge that I have been given time to read and have completely read (or had read to me) the preceding information in this document and I acknowledge that the Practice has explained to me in general terms the descriptions of certain anticipated dental procedures and treatments, alternatives (including non-treatment), and the risks and inconveniences of treatments. By proceeding with each and every step in my treatment, I acknowledge that: (1) I have been given the opportunity to ask any questions and any questions have been answered or explained to my satisfaction prior to performance of any treatment or procedure, and (2) I authorize the Practice to perform any and all such recommended forms of treatment, medication and therapy that may be necessary or advised. I understand that during the course of the procedures described above, it may be necessary, appropriate, or the Practice’s recommendation to perform additional procedures which are unforeseen or not known to be necessary, appropriate, or recommended at the time this consent is given. I consent to and authorize the performance of such additional procedures as they deem necessary, appropriate, or recommended under the circumstances.

SIGNATURE
 
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Patient’s Authorized Representative

(If patient is under 18 years of age or you are consenting to the care of another)
I have the legal authority to sign this consent on behalf of:

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NOTICE OF PRIVACY PRACTICES


As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

THIS NOTICE DESCRIBES HOW CERTAIN HEALTH INFORMATION ABOUT YOU, AS A PATIENT OF THIS PRACTICE, MAY BE USED, DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

In conducting our business, the doctors and staff of the Atlanta Center for Cosmetic Dentistry ("ACCD,""our" or "we") create records regarding you and the treatment and services that we provide to you. We are committed to abide by all applicable laws regarding the protection of your individually identifiable health information ("health information"). This notice is intended to provide information to you about our privacy practices, our legal duties, and your rights concerning your health information.

This notice is effective as of April 14, 2003 (the "Effective Date") and its scope applies to all records containing your health information that are retained or created by us after the Effective Date. We reserve the right to change our privacy practices and the terms of this notice at any time, and such new privacy practices will be effective for any records that we have created or maintained in the past or that we may create or maintain in the future. Before we make any material changes in our privacy practices, however, we will make our new notice available upon request.

OUR USES AND DISCLOSURES OF HEALTH INFORMATION

For Treatment: We may use your health information to provide you with dental treatment and related services. We may disclose your health information to other dental offices, dentists, physician offices, laboratories, providers, agencies, facilities, pharmacies, transport companies, family members, or other health care providers and their staff involved in providing health related treatment, services or care to you. For example, we may disclose your health information to a pharmacy to write a prescription for you. We may communicate with you about or recommend possible treatment options or alternatives that may be of interest to you. We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters) or informational or promotional materials such as practice newsletters.

For Payment: We may use and disclose your health information (e.g., x-rays, billing statements, etc.) to persons or entities (e.g., insurance companies, family members, third party payers, health plans) so that you (or we as the case may be) can be reimbursed for treatment and services we provide to you.

For Health Care Operations: We may use and disclose your health information for our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence of health care professionals, evaluating practitioner and provider performance, conducting educational or training programs, accreditation, certification, licensing or credentialing activities or to detect or prevent health care fraud and abuse, contractual obligations, patients' claims, grievances or lawsuits, health care contracting, legal, tax, or business planning and development, business management and administration, promotional programs, the sale of all or part of ACCD to another entity, underwriting, claims management and other insurance activities. We may disclose your health information to another health care provider or organization to support some of their health care operations.

Relatives, Caregivers and Personal Representatives: We may disclose your health information to a family member, friend, personal representative, or other person you identify that is involved in your dental or health care or with payment for your dental or health care. Unless you have otherwise provided us the authorization to do so, before we disclose your health information to such people, we will provide you with an opportunity to object to our use or disclosure. If you are not present, or in the even of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We may 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 filled prescriptions, medical supplies, x-rays, or other similar forms of health information. We may use or disclose information about you to notify or assist in notifying a person involved in your care, of your location and general condition.

Health Related Benefits and Services: We may contact you about benefits or services that we provide.

Disaster Relief Efforts: We may use or disclose your health information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.

News Gathering Activities: We may contact you or one of your family members to discuss whether or not you want to participate in a media or news story (e.g., a news reporter working on a story about dental health may ask whether any patients undergoing some sort of specific dental treatment may be willing to interviewed).

Public Benefit: We may use or disclose your medical information as authorized by law for the following purposes deemed to be in the public interest or benefit, including without limitation, for public health activities, including disease and vital statistic reporting, child abuse reporting, FDA oversight, and to employers regarding work-related illness or injury; to report adult abuse, neglect, or domestic violence; to health oversight agencies; to coroners, medical examiners, and funeral directors; to an organ procurement organizations; to avert a serious threat to health or safety; in connection with certain research activities; and to the military and to federal officials for lawful intelligence, counterintelligence, and national security activities.

As Authorized or Required By Law: We will disclose health information when authorized or required to do so by applicable law, including without limitation, in response to court and administrative orders and other lawful processes; to law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person; to correctional institutions regarding inmates; and as authorized by state workers' compensation laws.

Lawsuits and Similar Proceedings: In connection with lawsuits or other legal proceedings, we may disclose health information about you in response to a court or administrative order, or in response to a subpoena, discovery request, warrant, summons, or other lawful process. We may disclose health information to courts, attorneys, and court employees in the course of litigation, arbitration, or other judicial or administrative proceedings.

Law Enforcement: If asked to do so by law enforcement, and as authorized or required by law, we may release medical information: to identify or locate a suspect, fugitive, material witness, or missing person; about a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement; about a death suspected to be the result of criminal conduct; about criminal conduct at ACCD; and in case of a medical emergency, to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors: In most circumstances, we may disclose medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine cause of death. We may also disclose medical information about patients of ACCD to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities: As authorized or required by law, we may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities.

Other Uses of Health Information: Not every specific use or disclosure of your health information is listed in this notice. Unless you provide us (or have already provided us) with separate written authorization to use or otherwise disclose certain personal or health information for certain purposes, all of the ways we are permitted to use and disclose health information will fall within one of the following categories.

PATIENT RIGHTS

Your health information that we have created and maintain is the property of ACCD. You have the following rights, however, regarding your health information that we maintain.

Right to Inspect and Copy: You have the right to look at or get copies of your health information, with certain exceptions. You may make reasonable requests that we provide copies in a format other than photocopies. We will use the format you request unless it is unduly burdensome to do so. You must make a request in writing to obtain access to your health information by sending a letter to the Privacy Officer identified at the bottom of this notice. If you request copies, we will charge you a fee for these services that may include labor, duplication costs, and postage. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we may – but are not required to – prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this notice for more information about fees.

Right to Amend: You have the right to request that we amend your health information if you believe that the health information that we have about you is incorrect or incomplete. Your request must be in writing to the Privacy Officer identified at the bottom of this notice, and it must explain reasons that support your request to amend your health information. We may deny your request under certain circumstances (e.g., it is not in writing, does not have support for the request, asks that we amend information that is accurate or complete, was not created by ACCD, etc.).

Right to Disclosure Accounting: You have the right to request a list of certain disclosures we have made of your health information. To request this accounting of disclosures, you must submit your request in writing to the Privacy Officer identified at the bottom of this notice. Your request must state a time period longer than the previous six years and may not include dates before April 14, 2003. That list will not include disclosures for treatment, payment, health care operations, as otherwise authorized by you, and for certain other activities. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Contact us using the information listed at the end of this notice for more information about fees.

Right to Request Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information for treatment, payment or healthcare operations. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). In your request, you must tell us: (1) what information you want us to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. We are not required to agree to your request. If we do agree, our agreement must be in writing signed by a person authorized to make such agreement on our behalf and we will endeavor to comply unless the information is needed to provide emergency treatment.

Right to Alternative Communication: You have the right to request that we communicate with you about your health information in a certain way or at a certain location. You must make your request in writing to the Privacy Officer identified at the bottom of this notice. You must specify in your request the alternative means or location, and provide satisfactory explanation how you will handle alternative payment under the alternative means or location you request. We will endeavor to comply with all reasonable requests.

Right to Copies of This Notice: You may request a paper copy of our notice and we will endeavor to keep a current copy posted on our website located at www.AtlantaCenterForCosmeticDentistry.com. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.

Right to File A Complaint: You may contact the Privacy Officer listed at the bottom of this notice if you believe that we have violated your privacy rights, we made a decision about access to your health information incorrectly, our response to a request you made to amend or restrict the use or disclosure of your health information was incorrect, or we should communicate with you by alternative means or at alternative locations. You also 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 with the U.S. Department of Health and Human Services upon request. We will not penalize you on the basis of filing a complaint.

ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I received a copy of the Notice of Privacy Practices and authorize the disclosure of identifying health information.

SIGNATURE
 
(Please click below to draw/upload sign)
(Your IP Address : )

Office Financial Policy

Payment is expected at time of service. We will accept cash, check, or credit card. Checks accepted with valid driver’s license only.

We accept insurance. We will file your claims at no charge. It is the patient’s responsibility to provide us with current insurance information.

If any payment from an insurance company becomes 30 days past due, you will be immediately billed for the entire balance.

We will file pre-treatment estimates, AT YOUR REQUEST ONLY. Please be aware that some insurance companies may not honor a pre-treatment estimate or may alter it. In all cases it may delay important dental care.

Not all services are covered by insurance. In the event your insurance plan determines a service to be “not covered”, you will be responsible for the complete charge. Our staff can never guarantee your eligibility and coverage.

Insurance limitations and regulations vary with all insurance plans. Therefore, if your insurance plan denies a service, you will be responsible for the complete charge. We do not base your treatment plan on what your insurance plan covers or doesn’t cover. We are working for you, not the insurance company.

Past due accounts may be turned over to a collection agency. Any fees incurred due to this, will be added to the outstanding balance. This may include late fees, collection agency fees, court fees etc.

SIGNATURE
 
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(Your IP Address : )

Missed Appointment Policy

Due to the high number of patients requiring dental care, waiting times for appointments can be long. Because of this, we enforce a missed appointment policy to ensure that other patients receive care in a timely manner. Missed appointments and appointments cancelled without 24-hour notice are subject to a cancellation fee of 50$.

Recieve Appointment Reminders Via Email And Text

Please check a source in which you would like to recieve appointment reminders.*

Email  
Text Message  
Both Email and Text Message

We use this information to provide you with excellent treatment. We may disclose Patient Health Information (PHI) to third parties that perform services for Atlanta Center for Cosmetic Dentistry in the administration of your benefits in accordance with HIPAA. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. Your PHI may be disclosed to an affiliate that performs services for Atlanta Center for Cosmetic Dentistry in the administration of your benefits. Our affiliates do not sell, share or rent our users’ personally identifiable information unless required by law, do not send and e-mail or other communications without user permission, and do not send spam.

SIGNATURE
 
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(Your IP Address : )
Thank you for visiting Atlanta Center for Cosmetic Dentistry. We want your visit to be pleasant and comfortable. Please help us by completing this form
Patient Information

Personal Details

Title:     First Name:     Last Name:    
Date Of Birth:     Social Security Number:    
Gender:     Marital Status:    
Is the Patient Under 18( Miner )? Yes No

Guardian Details

First Name:     Last Name:     Date Of Birth:    
Phone Number:     Relation to Patient:    
How did you hear about our office?:    

Address

Street Address:     City:     State:     Zip:    
Home Phone:     Cell Phone:     Work Phone:    
Email Address:     Driver's License:    

Emergency Contact Information

Name:     Relation:    
Home Phone:     Work Phone:    
Address:     City:     State:     Zip Code:    

Professional Information

Employer Name:     Position:    
Employer Address:     City:     State:     Zip Code:    
Are You Employed? Yes No

Spouse Information

Spouse Name:     Date Of Birth:    
Phone Number:     Employer:    
Are You Married? Yes No

Primary Insurance Information

Dental Coverage Yes No Unknown
Medical Coverage Yes No Unknown
Orthodontic Coverage Yes No Unknown
Insurance Co. Name:     Phone Number:    
Group (Plan , Local , Policy):    
Insurance Co.Address:     City:     State:     Zip Code:    
Insured Name:     Insured Birth Date:    
Insured Social Security:     Relation:    
Insured Employer:    
Employer's Address:     City:     State:     Zip Code:    
Do You have Primary Insurance? Yes No

Secondary Insurance Information

Dental Coverage Yes No Unknown
Medical Coverage Yes No Unknown
Orthodontic Coverage Yes No Unknown
Insurance Co. Name:     Phone Number:    
Group (Plan , Local , Policy):    
Insurance Co.Address:     City:     State:     Zip Code:    
Insured Name:     Insured Birth Date:    
Insured Social Security:     Relation: Relation:    
Insured Employer:    
Employer's Address:     City:     State:     Zip Code:    
Do You have Secondary Insurance? Yes No

Responsible Person for Account

Name:     Relation    
Home Phone:     Social Security number:    
Address:     City:     State:     Zip:    
Employer:     Work Phone:    
Billing Address:     City:     State:     Zip:    
Medical History
Are you under a physicians care now?
Yes
No
Details:
Have you ever had a serious head or neck injury?
Yes
No
Details:
Are you taking any medication, pills or drugs?
Yes
No
Details:
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Yes
No
Details:
Do you take, or have you taken, Phen-fen or Redux?
Yes
No
Details:
Have you ever been hospitalized or had a major operation?
Yes
No
Details:
Are you on a special diet?
Yes
No
Do you use tobacco?
Yes
No
Are you a woman?
Yes
No
Pregnant/trying to get pregnant Nursing Taking oral contraceptives None
Are you allergic to any of the following?
Aspirin Penicillin Codeine Acrylic
Metal Latex Sulfa drugs Local anesthetics
Others
Details:
Do you use controlled substances?
Yes
No
Details:
Do you or Have you experienced the following ?
AIDS/HIV Positive Alzheimers disease Anaphylaxis
Anemia Angina Arthritis/Gout
Artificial Heart Valves Artificial Bones/Joints Asthma
Blood Disease Blood Transfusion Breathing Problems
Bruise Easily Cancer Chemotheropy
Chest Pain Cold sores / Fever blisters Congenital heart disorder
Convulsion Cortisone medicine Diabetes
Difficulty Breathing Drug Addiction Easily Winded
Emphysema Epilepsy or Seizures Excessive Bleeding
Excessive Thirst Fainting spells / Dizziness Frequent Cough
Frequent Diarrhea Frequent Headaches Genital Herpes
Glaucoma Hay Fever Heart Attack / Failure
Heart Murmer Heart Trouble / Desease Hemophilea
Hepatitis A Hepatitis B or C Herpes
High Blood Pressure High Cholesterol Hives or Rash
Hypoglycemia Irregular Heartbeat Kidney Problem
Leukemia Liver Disease Low Blood Pressure
Lung diseases Mitral Value prolapse Osteoporosis
Pain in Jaw Joints Parathyroid Disease Psychiatric Care
Radiation Treatments Recent Weight Loss Renal Dialysis
Rheumatic Fever Rheumatism Scarlet Fever
Shingles Sickle Cell Disease Sinus Trouble
Spina Bifida Stomach/Intestinal Disease Stroke
Swelling of Limbs Thyroid Disease Tonsillitis
Tuberculosis Tumors or Growths Ulcers
Venereal Disease Yellow Jaundice
Have you ever had serious illnesses not listed?
Yes
No
Details:
Dental History
Purpose Of Visit
Are you currently in pain?
Yes
No
Do you require antibiotics before dental treatment?
Yes
No
Do you now or have you ever experienced pain/ discomfort in your jaw joints (TMJ/TMD)?
Yes
No
Do you floss daily?
Yes
No
Do you use anything in addition to your brush and floss?
Yes
No
Details:
Would you like whiter teeth?
Yes
No
Do your gums ever itch?
Yes
No
Do you brush daily?
Yes
No
Would you like fresher breath?
Yes
No
Do your gums ever bleed?
Yes
No
Have you ever had Periodontal disease?
Yes
No
Do you have mobility in teeth?
Yes
No
Do you still have wisdom teeth?
Yes
No
Details:
Your current dental health is
Good
Fair
Poor
Type of bristles on your toothbrush?
Hard
Medium
Soft
Are your teeth sensitive to?
Heat
Cold
Other
Previous Dental Practice name: Last visit to a Dental Office:
Are you happy with the way your smile looks?
Yes
No
Details:

Treatment Authorization

The information on this page is correct to the best of my knowledge. I authorize and give consent to perform dental services agreed between doctor and patient and/or parent or guardian to be necessary or advisable including the use of local anesthesia and other medication as indicated. I certify to the above statements regarding my medical condition.

The information on this page is correct to the best of my knowledge.
 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

PRACTICE AGREEMENT

INFORMATION ABOUT YOUR DENTAL TREATMENT

The purpose of the following sections are to inform you of the procedures that we routinely perform here, to emphasize the importance of your role and cooperation in achieving a high level of oral health and beauty, and to point out the potential risks and inconveniences that may be encountered before, during and after treatment.

DESCRIPTIONS OF CERTAIN DENTAL PROCEDURES

Your dental treatment may involve one or a combination of the following procedures that are summarized below.
Examinations & Hygiene Cleanings: The initial examination and hygienic cleaning are intended in part to evaluate and make recommendations regarding the health and appearance of your teeth and gums. The dental exam, hygienic cleaning, and any basic restorative (e.g., fillings) or gingival therapy may involve the touching, scaling, or periodontal probing of your teeth and oral tissues. Other or subsequent hygienic procedures (periodontal scaling, root planning, etc.) may be indicated and performed as well depending on your condition. These procedures are designed to remove plaque or calculus from your teeth and help maintain or restore the health of your gums.
A Bridge is a replacement made for missing teeth. It is usually composed out of porcelain or porcelain fused to a harder substance like metal, which is bonded to adjacent teeth. These abutment teeth may require some reduction or crowning in order to support the teeth being replaced.
Crowns, Veneers, and other porcelain restorations and enhancements are designed to be life-like looking tooth restorations made out of porcelain or porcelain plus other materials. A crown usually covers the entire tooth structure (although there are 3/4 crowns and other variations). Typically, more tooth structure is removed to prepare for a crown placement than for a veneer (which may entail zero, minimal or significant tooth reduction, depending on the circumstances). Crowns may be recommended for teeth requiring additional support due to a loss of healthy tooth structure. Veneers primarily cover the front of the teeth, although some varieties also have porcelain on the backside of teeth. While the porcelain enhancements are being fabricated, you will have temporary crowns or veneers, which are not intended to be permanent and are easier to remove or pop off.
Fillings or Bonding are terms that are commonly used to refer to the placement of composite resins or other appropriate materials in cavities or on teeth. Bonding can be used to make a tooth colored filling for small cavities and repair broken or chipped tooth surfaces. It can also be used to close spaces between teeth. We have not placed amalgam fillings (sometimes called silver or mercury fillings) in over a decade because we believe that there are more desirable materials such as tooth colored composites and porcelain. Although some people have had amalgams for many years, we do usually remove amalgam fillings at the patients’ request. We want to make you aware that amalgam suppliers report that after placement or removal of amalgam fillings, there can be a slight, but measurable increase in mercury in your blood and/or urine.
Inlays or Onlays may be the recommended treatment when teeth have had decay or are broken down but retain enough healthy tooth structure to allow for restoration of certain voids in the tooth structure. The tooth is prepared much like a normal filling. The restoration material is custom fabricated out of composite resins, porcelain, or metal, and then bonded into the void.
Whitening is performed by applying a peroxide gel to the teeth. This can either be done in our office with an accelerated method or through a take home system. The peroxide reacts with the tooth structure to safely whiten the teeth. Porcelain or composite restorations will not whiten with peroxide whitening systems. At least one recent study has indicated that mercury from amalgam fillings can be released by prolonged exposure to peroxide based whitening gels.
Tooth Contouring is the reshaping of existing tooth structure by removing small amounts of enamel, usually around the edges. We give particular attention to the edges of the upper and lower front six teeth, which may be reshaped to create a more aesthetic result.
Gum Contouring is the reshaping of the gum tissue, which is many times done to give a more symmetrical appearance. This is usually done with a laser or electrosurge. In the hands of an experienced cosmetic dentist, it is a relatively simple, but dramatic procedure. Most patients report that for a day or so afterwards, it feels somewhat similar to a pizza burn when you eat pizza that’s too hot.
Root Canal Therapy can be indicated anytime that a tooth receives trauma or has dental work performed on it. In general, the more trauma or amount of work, the higher the risk is that a root canal will be needed. This therapy consists of removing the damaged or infected nerve in the tooth and replacing it with a sterile material. If there are existing restorations in place, this procedure can many times be performed by accessing the tooth through an access hole in the restoration and then repairing it without destroying the restoration, although destruction of the existing restoration is a risk as well. The Practice attempts to predict and notify you in advance of the likelihood of root canal therapy depending on your procedure, however, all people are different and the human body can react in a myriad of unpredictable ways. Thus, it is difficult or impossible to make accurate predictions of this sort in the vast majority of cases. Therefore, regardless of cause, should you require subsequent root canal therapy or restorative work (whether obtained here or at another office), which has not been paid for as part of your Treatment Plan, you agree to be responsible for those costs.
Local Anesthetic of various types may be used to block certain nerve impulses and numb the oral tissues before certain dental treatments. These are administered by injections to prepare for a number of both simple and complex dental and periodontal procedures.
Nitrous Oxide is sometimes called "laughing gas" and can result in feelings of relaxation, a reduced sense of fear or anxiety, increased tolerance to pain or discomfort, an altered perception of time, a tingling sensation, especially in fingers and toes, giddiness or light headedness, nausea, vomiting, incontinence, hallucinations or dreams. While the use of nitrous oxide is safe and effective for most people, it is not recommended for use on all patients. If you have any of the following conditions, you may not be a good candidate for the use of nitrous oxide: chronic obstructive pulmonary disease (emphysema), upper respiratory or throat infections, any acute respiratory conditions such as cold, flu, or sinus infection, claustrophobia, compulsive personality, taking any psychiatric mood altering drug, bowel obstructions, middle ear disturbances or pregnancy. Please notify the Practice doctor if you have any of these conditions and we will discuss other options that may be available.

ADDITIONAL TREATMENT INFORMATION

Specific Results Are Not Guaranteed
The dental procedures described above have a very high degree of success at our Practice. The human body, however, reacts differently to different dental treatments depending on a wide variety of factors. Each individual is different and the exact result for each specific case is difficult if not impossible to guarantee. Thus, as with any branch of medicine or dentistry, our treatment carries with it no guarantee of specific results. There are many variables that affect how long restorations, whitening, or other dental treatments can be expected to last and how the teeth and gums will react, including but are not necessarily limited to, general health, maintenance of good oral hygiene, regular dental checkups, etc. No matter how well done, chipping, breaking or loosening of dental work can occur. No guarantees can be made or assumed regarding the results or longevity of restorations, whitening, or other dental treatments.If you are provided a computer generated imaging of your smile, you understand that this is an artificial mechanism to serve as a basis for a discussion of treatment, and in no way provides a warranty or representation of specific results.
Alternative Treatments & Providers There is usually more than one way of doing things and there may be alternative treatments to what the Practice recommends for you, which may include, but are not necessarily limited to one or more various combinations of veneers, crowns, bonding, onlays, inlays, whitening, contouring of teeth or gums, bridges, dentures, extractions, root canal therapy, fillings, orthodontics, non-surgical therapy, surgical cuterage or cleaning, tooth extractions, implant treatments, as well as a variety of other dental treatments. All dental treatments have risks, so please make sure you have had an opportunity to ask about these alternatives and have them explained to your satisfaction. In addition, the dental treatments in our office are typically, but not always, performed by a general dentist. Another option is for you to have some of the above treatments done by one or more specialists (e.g., orthodontist, endodontist, oral surgeon, etc.). After hearing general descriptions of alternative treatments, if you would like a referral to any dental specialist, let us know and we will be happy to provide a referral. If you do not ask for a referral and proceed with the treatment, this will be considered by us to mean you have declined our offer for a referral.
Non-Treatment Option
One option is to have no treatment performed. This alternative may entail a number of actual or potential risks, each of which are difficult or impossible to quantify or predict for specific cases. Some of the risks of non-treatment may include, but are not necessarily limited to, exacerbation of any existing symptoms, deterioration of aesthetics or function of your teeth, improper biting, tooth, head and/or neck pain, fracturing of teeth, discoloration or staining of your teeth, rotation or movement of teeth, TMJ complications; additional wear of your teeth to the point they are not candidates for reconstruction, loss of teeth, bite problems, poor chewing, loosening of teeth, need for dentures, gum recession, bad breath, inability to perform adequate oral hygiene, abscesses or infection, pain, tooth sensitivity, tooth movements, worsening periodontal condition, deeper pockets, and other oral health problems.
Risks and Inconveniences
Inherent in your treatment plan (as well as with many similar or other dental procedures) are certain actual and potential risks and inconveniences, which vary based on individual circumstances and variations in teeth and gums. These risks and inconveniences may last for a short or an indefinable length of time.
General dental inconveniences and risks include, but are not necessarily limited to, bruising; discoloration; recession; abscesses; the need to repeat all or part of the procedure for known or unknown reasons; exposure of crown margins or edges; lisping; speech impediments or speaking difficulties; infections, virus; stretching of the mouth resulting in cracked corners; tooth mobility; oral surgery; food impaction; root staining; oral opening restrictions; tissue sloughing; the onset of or continued periodontal disease; root canal therapy; numbness of lip, chin, and gums; dental neuropathy; gagging; numbness; joint pain/disorder; accidental nicks or cuts from dental instruments or needle sticks to the body; chipping, breaking or fillings in other teeth; other tissues; loosening of the temporary or permanent restorations; tempromandibular joint (jaw joint) problems; nausea; bone or tooth fracture; adverse reaction to drugs, medications, and/or anesthetic (including nitrous oxide); dyspepsia; gum hemorrhage; mouth ulceration; nausea; tongue edemas; tooth disorder; varying psychological reactions; dental work that does not match the color of surrounding teeth or dental work; trapping of saliva or food; loss of surface shine from restorations; ledges; or local tissue necrosis.
The most common risks include, but are not necessarily limited to, swelling; tooth sensitivity; bleeding; gum irritation; gum, bone or teeth inflammation; stiffness of facial muscles; temporary numbness or tingling in the lip, tongue, teeth, gums, chin, cheek or jaw area; changes in occlusion; need for a night guard; permanent reduction of tooth structure; a need for you to modify the frequency or methodology of your home hygiene care (e.g., brushing and flossing to adequately go around corners, edges, etc.); or wearing temporary teeth for an undefined period of time as well as the general dental inconveniences and risks set forth above.
The more remote general dental risks include, but are not necessarily limited to, loss of teeth; implant rejections; permanent numbness or tingling in the lip, tongue, teeth, gums, chin, cheek or jaw area; severe pain; permanent or temporary injuries to the nerves of the tongue, jaw, chin and lips, including lingual nerve injury (tongue) and inferior alveolar nerve damage (lips, chin and jaw), permanent or temporary numbness or loss of taste sensation; permanent or temporary structural injuries to the tongue, jaw, chin or lips; parasthesia; sutures, accidentally swallowing or aspirating restorations, materials or dental tools, changes in facial appearance, referred pain to the ear, neck, jaw or head, allergic reaction, delayed healing, sinus complications, constipation, diarrhea, vomiting; aspiration of vomit; systemic toxicity, respiratory distress, heart failure, or death. There may be additional unknown or unlisted risks at this time, but that could manifest at a later time. You understand that your condition may be the same, better or worse after treatment. If previously placed dental restorations are in place on teeth, your treatment may entail additional alteration of tooth structure to properly prepare these teeth for new restorations, and/or other unknown or unspecified problems or risks, which the Practice may or may not have encountered, and which are difficult or impossible to predict or quantify in advance.

YOUR OBLIGATIONS

Cooperation
Successful dental treatment is a team effort involving you as the patient, the doctors and our team. Without cooperation, successful treatment planning, achieving optimal results and maintaining the treatment results are difficult or impossible and the results may be disappointing to everyone.
Scheduled Appointments
In order to serve our patients better, we strive to operate a professional, efficient dental practice. We attempt to reserve appropriate blocks of time for each of our patients so that the procedures may be completed with close attention to detail and with as few interruptions as possible. Missed appointments have a negative effect on our ability to maintain the level of service you and other patients deserve. While we are aware that circumstances may arise which interfere with set appointments, we require two business days notice for an appointment of 2 hours or less and one week notice for entire morning appointmentsso that we may attempt to contact other patients awaiting time for treatment. Failure to provide this notice may result in a missed appointment fee which is, not intended as a penalty, but as a reasonable estimate of the time and expense incurred by the Practice in attempting to fill such a cancellation or loss of deposit.

Financial Obligations
You have full responsibility for payment of the dental services that you or your dependents receive here. Fees are due and payable in full at or before the time services are rendered. A 1.5% finance charge (18% annually) will be added to any balance over 30 days past due. In the event of your failure to pay amounts owed when due, you agree to pay for collection costs and reasonable attorneys fees as may be incurred for collection. Any dispute arising out of the Practice’s services or collection are subject to the Federal Arbitration Act and at the Practice’s sole option, will be submitted to binding arbitration with the American Arbitration Association in Atlanta.

Providing Timely Information & Authorization for Signature on File
To process insurance documents, claims and related matters, you authorize the Practice to affix your signature and name to claims or documents related to insurance, claims or health benefits due to you. A photocopy of this form will act as an original. The Practice may disclose information provided by me or obtained during the course of my treatment for treatment, payment, or healthcare operations, including disclosure to laboratories, other dental offices, or professionals involved in my care, and to my insurance providers. As part of your treatment, you authorize the Practice to take radiographs (x-rays), study models, provide injections, take photographs, and give and perform any other diagnostic tests and aids deemed appropriate by the Practice to evaluate your condition and to generate my recommendations, for professional or educational purposes and for any other use as contemplated or set forth in the Practice’s current Notice of Privacy Policies, which isincorporated herein by reference.

Maintenance Obligations
For successful treatment results and to lessen the risks of complication, you agree to comply with your individualized maintenance program and keep excellent home oral hygiene. It is typical to need follow-up visits for occlusal or other adjustments after treatment. You agree to notify the Practice at the soonest possible moment in the event that you experience pain, discomfort or any other problem that you believe may be related to treatment in our office. Nothing in this form extends the applicable statutes of repose or limitations for dental services. You agree to keep your follow-up appointments and to follow recommended treatments as well as follow other precautions and recommendations that may be provided as part of your pre-op or post-operative instructions.

YOUR CONSENT

The information I have provided on this form is accurate and complete to the best of my knowledge, information, and belief. I will notify the Practice at the soonest practical moment of any changes in the information I have provided. In consideration of being accepted as a patient of the Practice, I agree to abide by the terms and conditions of this Patient Application & Practice Agreement.

By signing below, I acknowledge that I have been given time to read and have completely read (or had read to me) the preceding information in this document and I acknowledge that the Practice has explained to me in general terms the descriptions of certain anticipated dental procedures and treatments, alternatives (including non-treatment), and the risks and inconveniences of treatments. By proceeding with each and every step in my treatment, I acknowledge that: (1) I have been given the opportunity to ask any questions and any questions have been answered or explained to my satisfaction prior to performance of any treatment or procedure, and (2) I authorize the Practice to perform any and all such recommended forms of treatment, medication and therapy that may be necessary or advised. I understand that during the course of the procedures described above, it may be necessary, appropriate, or the Practice’s recommendation to perform additional procedures which are unforeseen or not known to be necessary, appropriate, or recommended at the time this consent is given. I consent to and authorize the performance of such additional procedures as they deem necessary, appropriate, or recommended under the circumstances.

 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

Patient’s Authorized Representative

(If patient is under 18 years of age or you are consenting to the care of another)
I have the legal authority to sign this consent on behalf of:

Patient Name:     Your Relationship to Patient:    
The information on this page is correct to the best of my knowledge.
 
 
 
PATIENT OR PARENT/GUARDIAN SIGNATURE DATE & IP ADDRESS

NOTICE OF PRIVACY PRACTICES


As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA)

THIS NOTICE DESCRIBES HOW CERTAIN HEALTH INFORMATION ABOUT YOU, AS A PATIENT OF THIS PRACTICE, MAY BE USED, DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

In conducting our business, the doctors and staff of the Atlanta Center for Cosmetic Dentistry ("ACCD,""our" or "we") create records regarding you and the treatment and services that we provide to you. We are committed to abide by all applicable laws regarding the protection of your individually identifiable health information ("health information"). This notice is intended to provide information to you about our privacy practices, our legal duties, and your rights concerning your health information.

This notice is effective as of April 14, 2003 (the "Effective Date") and its scope applies to all records containing your health information that are retained or created by us after the Effective Date. We reserve the right to change our privacy practices and the terms of this notice at any time, and such new privacy practices will be effective for any records that we have created or maintained in the past or that we may create or maintain in the future. Before we make any material changes in our privacy practices, however, we will make our new notice available upon request.

OUR USES AND DISCLOSURES OF HEALTH INFORMATION

For Treatment: We may use your health information to provide you with dental treatment and related services. We may disclose your health information to other dental offices, dentists, physician offices, laboratories, providers, agencies, facilities, pharmacies, transport companies, family members, or other health care providers and their staff involved in providing health related treatment, services or care to you. For example, we may disclose your health information to a pharmacy to write a prescription for you. We may communicate with you about or recommend possible treatment options or alternatives that may be of interest to you. We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters) or informational or promotional materials such as practice newsletters.

For Payment: We may use and disclose your health information (e.g., x-rays, billing statements, etc.) to persons or entities (e.g., insurance companies, family members, third party payers, health plans) so that you (or we as the case may be) can be reimbursed for treatment and services we provide to you.

For Health Care Operations: We may use and disclose your health information for our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence of health care professionals, evaluating practitioner and provider performance, conducting educational or training programs, accreditation, certification, licensing or credentialing activities or to detect or prevent health care fraud and abuse, contractual obligations, patients' claims, grievances or lawsuits, health care contracting, legal, tax, or business planning and development, business management and administration, promotional programs, the sale of all or part of ACCD to another entity, underwriting, claims management and other insurance activities. We may disclose your health information to another health care provider or organization to support some of their health care operations.

Relatives, Caregivers and Personal Representatives: We may disclose your health information to a family member, friend, personal representative, or other person you identify that is involved in your dental or health care or with payment for your dental or health care. Unless you have otherwise provided us the authorization to do so, before we disclose your health information to such people, we will provide you with an opportunity to object to our use or disclosure. If you are not present, or in the even of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We may 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 filled prescriptions, medical supplies, x-rays, or other similar forms of health information. We may use or disclose information about you to notify or assist in notifying a person involved in your care, of your location and general condition.

Health Related Benefits and Services: We may contact you about benefits or services that we provide.

Disaster Relief Efforts: We may use or disclose your health information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts.

News Gathering Activities: We may contact you or one of your family members to discuss whether or not you want to participate in a media or news story (e.g., a news reporter working on a story about dental health may ask whether any patients undergoing some sort of specific dental treatment may be willing to interviewed).

Public Benefit: We may use or disclose your medical information as authorized by law for the following purposes deemed to be in the public interest or benefit, including without limitation, for public health activities, including disease and vital statistic reporting, child abuse reporting, FDA oversight, and to employers regarding work-related illness or injury; to report adult abuse, neglect, or domestic violence; to health oversight agencies; to coroners, medical examiners, and funeral directors; to an organ procurement organizations; to avert a serious threat to health or safety; in connection with certain research activities; and to the military and to federal officials for lawful intelligence, counterintelligence, and national security activities.

As Authorized or Required By Law: We will disclose health information when authorized or required to do so by applicable law, including without limitation, in response to court and administrative orders and other lawful processes; to law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person; to correctional institutions regarding inmates; and as authorized by state workers' compensation laws.

Lawsuits and Similar Proceedings: In connection with lawsuits or other legal proceedings, we may disclose health information about you in response to a court or administrative order, or in response to a subpoena, discovery request, warrant, summons, or other lawful process. We may disclose health information to courts, attorneys, and court employees in the course of litigation, arbitration, or other judicial or administrative proceedings.

Law Enforcement: If asked to do so by law enforcement, and as authorized or required by law, we may release medical information: to identify or locate a suspect, fugitive, material witness, or missing person; about a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person's agreement; about a death suspected to be the result of criminal conduct; about criminal conduct at ACCD; and in case of a medical emergency, to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime.

Coroners, Medical Examiners and Funeral Directors: In most circumstances, we may disclose medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine cause of death. We may also disclose medical information about patients of ACCD to funeral directors as necessary to carry out their duties.

National Security and Intelligence Activities: As authorized or required by law, we may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities.

Other Uses of Health Information: Not every specific use or disclosure of your health information is listed in this notice. Unless you provide us (or have already provided us) with separate written authorization to use or otherwise disclose certain personal or health information for certain purposes, all of the ways we are permitted to use and disclose health information will fall within one of the following categories.

PATIENT RIGHTS

Your health information that we have created and maintain is the property of ACCD. You have the following rights, however, regarding your health information that we maintain.

Right to Inspect and Copy: You have the right to look at or get copies of your health information, with certain exceptions. You may make reasonable requests that we provide copies in a format other than photocopies. We will use the format you request unless it is unduly burdensome to do so. You must make a request in writing to obtain access to your health information by sending a letter to the Privacy Officer identified at the bottom of this notice. If you request copies, we will charge you a fee for these services that may include labor, duplication costs, and postage. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we may – but are not required to – prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this notice for more information about fees.

Right to Amend: You have the right to request that we amend your health information if you believe that the health information that we have about you is incorrect or incomplete. Your request must be in writing to the Privacy Officer identified at the bottom of this notice, and it must explain reasons that support your request to amend your health information. We may deny your request under certain circumstances (e.g., it is not in writing, does not have support for the request, asks that we amend information that is accurate or complete, was not created by ACCD, etc.).

Right to Disclosure Accounting: You have the right to request a list of certain disclosures we have made of your health information. To request this accounting of disclosures, you must submit your request in writing to the Privacy Officer identified at the bottom of this notice. Your request must state a time period longer than the previous six years and may not include dates before April 14, 2003. That list will not include disclosures for treatment, payment, health care operations, as otherwise authorized by you, and for certain other activities. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests. Contact us using the information listed at the end of this notice for more information about fees.

Right to Request Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information for treatment, payment or healthcare operations. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). In your request, you must tell us: (1) what information you want us to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. We are not required to agree to your request. If we do agree, our agreement must be in writing signed by a person authorized to make such agreement on our behalf and we will endeavor to comply unless the information is needed to provide emergency treatment.

Right to Alternative Communication: You have the right to request that we communicate with you about your health information in a certain way or at a certain location. You must make your request in writing to the Privacy Officer identified at the bottom of this notice. You must specify in your request the alternative means or location, and provide satisfactory explanation how you will handle alternative payment under the alternative means or location you request. We will endeavor to comply with all reasonable requests.

Right to Copies of This Notice: You may request a paper copy of our notice and we will endeavor to keep a current copy posted on our website located at www.AtlantaCenterForCosmeticDentistry.com. For more information about our privacy practices, or for additional copies of this notice, please contact us using the information listed at the end of this notice.

Right to File A Complaint: You may contact the Privacy Officer listed at the bottom of this notice if you believe that we have violated your privacy rights, we made a decision about access to your health information incorrectly, our response to a request you made to amend or restrict the use or disclosure of your health information was incorrect, or we should communicate with you by alternative means or at alternative locations. You also 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 with the U.S. Department of Health and Human Services upon request. We will not penalize you on the basis of filing a complaint.

ACKNOWLEDGEMENT OF RECEIPT

I acknowledge that I received a copy of the Notice of Privacy Practices and authorize the disclosure of identifying health information.

The information on this page is correct to the best of my knowledge.
 
 
 
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Office Financial Policy

Payment is expected at time of service. We will accept cash, check, or credit card. Checks accepted with valid driver’s license only.

We accept insurance. We will file your claims at no charge. It is the patient’s responsibility to provide us with current insurance information.

If any payment from an insurance company becomes 30 days past due, you will be immediately billed for the entire balance.

We will file pre-treatment estimates, AT YOUR REQUEST ONLY. Please be aware that some insurance companies may not honor a pre-treatment estimate or may alter it. In all cases it may delay important dental care.

Not all services are covered by insurance. In the event your insurance plan determines a service to be “not covered”, you will be responsible for the complete charge. Our staff can never guarantee your eligibility and coverage.

Insurance limitations and regulations vary with all insurance plans. Therefore, if your insurance plan denies a service, you will be responsible for the complete charge. We do not base your treatment plan on what your insurance plan covers or doesn’t cover. We are working for you, not the insurance company.

Past due accounts may be turned over to a collection agency. Any fees incurred due to this, will be added to the outstanding balance. This may include late fees, collection agency fees, court fees etc.

 
 
 
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Missed Appointment Policy

Due to the high number of patients requiring dental care, waiting times for appointments can be long. Because of this, we enforce a missed appointment policy to ensure that other patients receive care in a timely manner. Missed appointments and appointments cancelled without 24-hour notice are subject to a cancellation fee of $50.

Recieving Appointment Reminders Via Email and Text

Please check a source in which you would like to recieve appointment reminders.

Email
Text Message
Both Email and Text Message
Email Address(if applicable)
Cell Phone(if applicable)

We use this information to provide you with excellent treatment. We may disclose Patient Health Information (PHI) to third parties that perform services for Atlanta Center for Cosmetic Dentistry in the administration of your benefits in accordance with HIPAA. These parties are required by law to sign a contract agreeing to protect the confidentiality of your PHI. Your PHI may be disclosed to an affiliate that performs services for Atlanta Center for Cosmetic Dentistry in the administration of your benefits. Our affiliates do not sell, share or rent our users’ personally identifiable information unless required by law, do not send and e-mail or other communications without user permission, and do not send spam.

 
 
 
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