New Patient Packet 2023 Form

Informed Consent For Dental Treatment

I understand that I have come to the office of Frank C. Greider, M.S., D.D.S., P.C. for routine dental treatment and I do hereby give my consent for this treatment. I have been advised that though good results are expected, the possibility and nature of complications cannot be accurately anticipated and that, therefore, there can be no guarantee as expressed or implied either as to the results or as to cure. Fees are guaranteed for 12 months from the date of this statement.

I hereby state that I have read and understood this consent, and that all questions about the procedures have been answered in a satisfactory manner.

Signature of Patient or Legal Guardian:

Date:

Witness:

Date:

I certify that I explained the above procedures to the patient and/or legal guardian before requesting their signature.

Frank C. Greider, M.S., D.D.S., P.C.

Date:

HIPAA OMNIBUS RULE

PATIENT ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES AND CONSENT / LIMITED AUTHORIZATION & RELEASE FORM

You may refuse to sign this acknowledgement & authorization in refusing we may not be allowed to process your insurance claims.

Date:

The undersigned acknowledges receipt of a copy of the currently effective Notice of Privacy Practices for this healthcare facility. A copy of this signed, dated document shall be as effective as the original. MY SIGNATURE WILL ALSO SERVE AS A PHI DOCUMENT RELEASE SHOULD I REQUEST TREATMENT OR RADIOGRAPHS BE SENT TO OTHER ATTENDING DOCTOR / FACILITIES IN THE FUTURE.

Type your name:

Sign your name:

Legal Representative:

Description of Authority:

Your comments regarding Acknowledgements or Consents:

PLEASE LIST ANY OTHER PARTIES WHO CAN HAVE ACCESS TO YOUR HEALTH INFORMATION: (This includes step parents grandparents, and any care takers who can have access to this patient's records):

Name:

Relationship:

Name:

Relationship:

In signing this HIPAA Patient Acknowledgement Form, you acknowledge and authorize that this office may recommend products or services to promote your improved health. This office may or may not receive third party remuneration from these affiliated companies. We, under current HIPAA Omnibus Rule, provide you this information with your knowledge and consent.

Office Use Only
As Privacy Officer, I attempt to contain the patient's (or representatives) signature on this Acknowledgement but did not because:

It was emergency treatment:

I could not communicate with the patient:

The patient refused to sign:

The patient was unable to sign because:

Other (please describe):

Name:

Suffix:

Street Address:

City:

State:

Zip:

Referred by:

Date of Birth:

Home Phone:

Cell Phone:

Business Phone:

Email:

SSN:

Physician:

Office Phone:

Preferred Pharmacy

Pharmacy Phone:

Describe any current medical treatment, impending surgery, or other treatment that may possibly affect your dental treatment.

Drug

Purpose

Drug

Purpose

Please answer YES or NO the following:

PERSONAL DENTAL HISTORY

Have you ever had complications from past dental treatment?

Yes

No

Have you ever had trouble getting numb or had any reactions to local anesthetic?

Yes

No

Did you ever have braces, orthodontic treatment or had your bite adjusted?

Yes

No

Have you ever had any teeth removed?

Yes

No

SMILE CHARACTERISTICS

Is there anything about the appearance of your teeth that you would like to change?

Yes

No

Have you ever whitened (bleached) your teeth?

Yes

No

Have you felt uncomfortable or self conscious about the appearance of your teeth?

Yes

No

Have you been disappointed with the appearance of previous dental work?

Yes

No

BITE AND JAW JOINT

Do you have any problems with your jaw joint? (pain, sounds, limited opening, locking, popping)

Yes

No

Do you/would you have any problems chewing gum?

Yes

No

Do you/would you have any problems chewing bagels, baguettes, protein bars, or other hard foods?

Yes

No

Are your teeth crowding or developing spaces?

Yes

No

Do you chew ice or have any other oral habits?

Yes

No

Do you clench your teeth in the daytime or make them sore?

Yes

No

Do you have any problems with sleep or wake up with an awareness of your teeth?

Yes

No

Do you currently wear a nightguard?

Yes

No

GUM AND BONE

Do your gums bleed when brushing or flossing?

Yes

No

Have you ever been treated for gum disease or been told you have lost bone around your teeth?

Yes

No

Have you ever noticed an unpleasant taste or ordor in your mouth?

Yes

No

Is there anyone with a history of periodontal disease in your family?

Yes

No

Have you ever experienced gum recession?

Yes

No

Have you ever had any teeth become loose on their own (without injury) or do you have difficulty eating apples?

Yes

No

Have you experienced a burning sensation in your mouth?

Yes

No

Patient's Signature:

Date:

Doctor's Signature:

Date:

Name:

Date:

Please tell us about your Preferences

Dr. Greider and his staff can better recommend the most suitable preventive and corrective dental treatment for you with your completion of the questionnaire below. Is it important that they understand your individual needs, desires and personal values to best understand what you want for yourself. Please help us personalize your dental care so to meet your expectations by indicating your choices or opinions below.

Please mark off the statement that most represents YOU:

I think I know a great deal about my dental condition/health.

Yes

OR

I don't know very much about my dental condition/health.

Yes

I prefer to be presented with fewer options.

Yes

OR

I prefer to be presented with as many options as possible.

Yes

I tend to look at all the details.

Yes

OR

I tend to look as the big picture.

Yes

I prefer long-term solutions. Possibly more costly.

Yes

OR

I prefer a temporary solution. Possibly lest costly.

Yes

I feel comfortable speaking in technical dental terminology.

Yes

OR

I prefer to in more simple dental terminology.

Yes

My choices in my dental care are largely determined by my dental insurance coverage.

Yes

OR

I make my own personal dental care decisions.

Yes

I act only when necessary for dental care.

Yes

OR

I prefer to take the preventive approach and not delay treatment.

Yes

Patient Validation: