Office Hours: 7:30am - 4:00pm, Monday-Thursday
Step 1 of 6 - Patient Info
Address Line 2
District of Columbia
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Patient Social Security #
Patient Date of Birth
Please choose contact preference
RESPONSIBLE PARTY / INSURANCE INFORMATION
Name or Parent / Subscriber
Subscriber/Policy Holder Address (if different from previous page)
Address Line 2
State / Province / Region
ZIP / Postal Code
Antigua and Barbuda
Bosnia and Herzegovina
Central African Republic
Congo, Democratic Republic of the
Congo, Republic of the
Northern Mariana Islands
Palestine, State of
Papua New Guinea
Saint Kitts and Nevis
Saint Vincent and the Grenadines
Sao Tome and Principe
Trinidad and Tobago
United Arab Emirates
Virgin Islands, British
Virgin Islands, U.S.
Date of Birth
Social Security #
Insurance Member ID #
Insurance Carrier Phone Number
Whom may we thank for referring you to our practice?
Another Patient, Friend
Another Patient, Relative
As a condition of your treatment by this office, financial arrangements must be made in advance. The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. Regardless of any dental insurance a patient may have, the full treatment fees are the responsibility of the patient, not the insurance company or the practice. Full payment of our fees is due at or before the time of treatment. I grant my permission to your assignee, to telephone me at home or at my work to discuss matters related to this form. I have read this form, agree to its terms, and certify I’ve provided all information completely and accurately.
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.
Are you under a physician's care now?
Have you ever been hospitalized or had a major operation?
Have you ever had a serious head or neck injury?
Are you taking any medications, pills, or drugs?
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Women: Are you
Pregnant or Trying to get Pregnant?
Taking oral contraceptives?
Are you allergic to any of the following?
Select any of the following conditions that you currently have or have had in the past
Artificial Heart Valve
Cold Sores/Fever Blisters
Congenital Heart Disorder
Epilepsy or Seizures
Hepatitis B or C
High Blood Pressure
Hives or Rash
Low Blood Pressure
Mitral Valve Prolapse
Pain in Jaw Joints
Recent Weight Loss
Sickle Cell Disease
Swelling of Limbs
Tumors or Growths
Have you ever had any serious illness not listed above?
Date of most recent dental exam
Date of most recent x-rays
Date of most recent treatment other than cleaning
I routinely see my dentist every:
How would you rate the condition of your mouth?
May we request records from your previous dentist to help facilitate your care?
Are you fearful of dental treatment?
Scale of 1 to 10 (very)
Have you had an unfavorable dental experience?
Have you ever had complications from past dental treatment?
Have you ever had trouble getting numb or reactions to local anesthetic?
Did you ever have braces, orthodontic treatment or had your bite adjusted??
Have you had any teeth removed?
Is there anything about the appearance of your teeth that you would like to change?
Have you ever whitened (bleached) your teeth?
Are you self conscious about your teeth?
Have you been disappointed with the appearance of previous dental work?
Bite & Jaw Joint
Do you/would you have any problems chewing gum?
Do you/would you have any problems chewing bagels or other hard foods?
Have your teeth changed in the last 5 years, become shorter, thinner or worn?
Are your teeth crowding or developing spaces?
Do you have more than one bite or do you clench (squeeze) to make your teeth fit together?
Do you have problems with sleep or wake up with an awareness of your teeth?
Do you have problems with your jaw joint?
(pain, sounds, limited opening, locking, popping)
Do you have tension headaches or sore teeth?
Do you wear or have you ever worn a bite appliance?
Have you had any cavities within the past 3 years?
Do you have a dry mouth?
Are any teeth sensitive to hot, cold, biting or sweets?
Have you ever had a toothache, cracked filling, broken, chipped or cracked tooth?
Do you avoid brushing any part of your mouth?
Do you feel or notice any holes (i.e. pitting) in your teeth?
Gum & Bone
Have you ever been diagnosed or treated for periodontal (gum) disease?
Have you ever experienced gum recession?
Is there anyone with a history of periodontal disease in your family?
Do your gums bleed when brushing, flossing or eating?
Are your teeth becoming loose?
Have you ever noticed an unpleasant taste or odor in your mouth?
Have you experienced a burning sensation in your mouth?
Thank you for choosing Austin City Dental to take care of your dental needs! Our primary mission is to deliver the best and most comprehensive dental care available. An important part of our mission is making the cost of dental care as easy and manageable for our patients as possible.
We accept Cash, Check, Visa, Mastercard, Discover and AMEX
Financial arrangements are provided on a case by case basis and can be discussed in detail when needed. Please let us know if this is something that we can assist you with to make your dental care possible prior to scheduling your appointment. We are also providers with Care Credit (outside financing company) who offers no interest payment options for up to 12 months. You may learn more about Care Credit by visiting their website at
Austin City Dental relies on payments from its patients and insurance companies. Payment is due in full for all appointments unless prior financial arrangements have been discussed and approved. As a courtesy to our patients, Austin City Dental will file your insurance for you and collect only your estimated portion for each visit. Should your insurance pay anything less than what is expected or estimated you will be responsible for any remaining balance that the insurance does not pay.
Please note that our office does not participate with any plans and is not an “in network” or a “contracted” provider with your insurance company
. Austin City Dental is not obligated to the insurance company’s fees and will not allow the insurance companies to dictate how we care for our patients.
Austin City Dental has an obligation to its patients to provide appointments in a timely manner so that their dental needs can be addressed. We ask for our patients assistance in helping us make it possible to care for other patients. Should you need to cancel or reschedule an appointment we ask that you provide us a courtesy call at least 48 hours prior to your appointment so that we may offer the appointment to another patient. Failure to provide proper notice may result in broken appointment fees. In addition we ask our patients to arrive on time to their appointments. Our office is based off of a schedule and we want to be kind and respectful to our other patients’ appointment times.
By signing below you agree to Austin City Dental’s financial policy. We are honored that you have chosen us to care for you. If you have any questions regarding your visits with us please do not hesitate to ask.
Patient or Responsible Party Signature
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOUR MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
Our Legal Duty
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 4/14/2003, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. 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.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
We may use and disclose your health information to obtain payment for services we provide to you.
We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those describe in this Notice.
To Your Family and Friends:
We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved in Care:
We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use of professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pickup filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
Marketing Health-Related Services:
We will not use your health information for marketing communications without your written authorization.
Required by Law:
We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect:
We may use or disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, letters, or emails).
You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable costbased fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $5-$20/x-ray or photo. $0.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. 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 will prepare a summary or an explanation of your health information for a fee. Contact us using he information listed at the end of the Notice for a full explanation of our fee structure.)
You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. 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 request.
You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances. Electronic Notice: If you receive this Notice on our Website or by electronic mail (e-mail), you are entitled to receive this Notice in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy right, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of the Notice. You also may submit a written complaint with 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 support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
I acknowledge that I have read and understand everything in the Notice of Privacy Practices
Please list anyone that Austin City Dental may discuss your treatment, appointments and/or financial obligations with (examples: parents, spouse, guardian or caretaker-specific names).
May we leave detailed messages regarding treatment and/or appointments on your voicemail?