DENTAL - ProSites, Inc.
DENTAL RIGHT TOUCH DENTAL
REGISTRATION 870 Crestmark Dr., Suite 100
(PLEASE PRINT) Lithia Springs, GA 30122
Date_________________ Home Phone (____)_____________________ Cell Phone (___)_________________________
DENTAL RIGHT TOUCH DENTAL
HEALTH HISTORY
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMAITON. PLEASE REVIEW IT CAREFULLY.
1. OUR PLEDGE REGARDING DENTAL INFORMATION
The privacy of your dental information is important to us. We understand that your medical information is personal and we are committed to protecting it. We created a record of the care and services you receive at our dental office. We need this record to provide you with quality care and to comply with certain legal requirements. This notice will tell you about the ways we may use and disclosure of dental information. Through out this notice we refer to your medical information as dental information.
2. OUR LEGAL DUTY
Law Requires Us to:
1. Keep your dental information private.
2. Give you this notice describing our legal duties, privacy practices, and your rights regarding your dental information.
3. Follow the terms of the current notice.
We Have the Right to:
1. Change our privacy and the terms of this at any time, provided that the changes are permitted by law.
2. Make the changes in our privacy practices and the new terms of our notice effective for all dental information that we keep, including information previously created or received before the changes.
Notice of Change to Privacy Practices:
1. Before we make an important change in our privacy practices, we will change this notice and make the new available upon request.
You have a Right to:
1. Look at or get copies of certain parts of your dental information. You may request that we provide copies in a format other than photocopies. We will use the format requested unless it is not practical for us to do so. You must make your request in writing.
PRIVACY PRACTICES ACKNOWLEDGEMENT
ACKNOWLEDGEMENT FORM
I have received the Notice of Privacy Practices and I have been provided an opportunity to review it.
Name___________________________________________________________
Birthdate:____________________________
Signature:_______________________________________________________
Date:______________________________
RIGHT TOUCH DENTAL
870 Crestmark Drive Ste. 100
Lithia Springs, GA 30122
678-945-0034
FINANCIAL POLICY
Welcome to our practice. We appreciate the trust you have placed in us by selecting our office. We will make every effort to honor that trust by providing the quality of dental care you require and deserve. One of our primary concerns will be to make you feel comfortable in our office. We feel that all of your visits to our office will be a pleasant and unique experience. While providing the very best quality of dentistry, we strive to keep our fees fair. Payments, co-payments and co-insurances are due at the time services are rendered. Forms of payment accepted by the office are CASH, INSURANCE ASSIGNMENT, CARE CREDIT, CITI FINANCIAL, MASTER CARD, VISA, AMERICAN EXPRESS CREDIT CARD and DISCOVER. Unfortunately we do not except BUSINESS or PERSONAL CHECKS.
DENTAL INSURANCE
As a courtesy and convenience to you, our office will submit charges for services rendered to your insurance carrier, but we consider the patient primarily responsible for the account. The service provided by our office amounts to an agreement between the patient and the dentist. The insurance relationship constitutes an agreement between the carrier and the patient. There is a wide variety of dental insurance coverage offered. Various programs cover from as little as 10% to as much as 80-100%. Every dental plan has a provision for limiting dollars disbursement by the insurance company for covered services. The type of plan purchased by your employer determines the type of services covered and the dollar amount assigned to it. Any CHARGES not covered under your plan are YOUR RESPONSIBILITY. If the balance on your account is not PAID IN FULL within 45 DAYS a $50 collections fee will be charged to your account until the balance is satisfied and the account will be turned over to a collection agency. Feel free to call us if you have any questions regarding your account or changes in your insurance. A simple phone call can prevent a MISUNDERSTANDING.
APPOINTMENTS
It is necessary that we work by appointments. We take great pride in our ability to honor the time reserved for you. Unfortunately, emergencies do occur which occasionally cause delays in our schedules. A patient who is uncomfortable is our immediate concern. We do allow time for emergencies. This helps keep us on time and guarantees you the opportunity to be seen when the need arises. If you cannot keep your scheduled appointment, please give us 48 HOURS notice so that someone else may use your appointment time to avoid a service charge of $50 per appointment hour. This charge is not a covered benefit under your INSURANCE plan. DEPOSITS may be required on certain procedures at the doctor’s discretion. Some insurance plans such as GA Medicaid require our office to report any missed or broken appointments. Right Touch Dental reserves the right to dismiss any patient for missed or broken appointments in excess of three times.
I UNDERSTAND AND AGREE TO THE ABOVE FINANCIAL AND INSURANCE POLICIES SET FORTH BY RIGHT TOUCH DENTAL, L.L.C.
Signature: ____________________________________________ Date: ______________________
RESPONSIBILITY AND CONSENT STATEMENT
Right Touch Dental, LLC
870 Crestmark Drive Suite 100
Lithia Springs, Georgia 30122
678-945-0034
Lisa Kimble, D.D.S
Date:___________________
I hereby authorize and request the performance of dental services for myself or for;
___________________________________ Age _____________________
___________________________________ Age _____________________
___________________________________ Age _____________________
I also give my consent to any advisable and necessary dental procedures, medications, or anesthetics to be administered by the attending dentist or by the supervised staff for diagnostic purposes or dental treatment.
I understand and acknowledge that I am financially responsible for the services provided for myself or the above named; regardless of insurance coverage.
_______________________________
Signature of Responsible party
________________________________
Relationship to Patient
Right Touch Dental
870 Crestmark Dr. Ste. 100
Lithia Springs, GA 30122
(678) 945-0034
Dr. Lisa Kimble
LAB CASE AMENDMENT
When treatment is rendered that requires an outside laboratory we will make every effort to have the laboratory case returned to our office in a timely manner. Once the case is returned the patient will be contacted immediately to schedule a return appointment.
This office will continue this effort to schedule the patient for up to 90 days after the laboratory case is returned to the office. This amendment is to inform the patient that we will not be held responsible for the consequences of not returning to the office in a timely manner and moving forward with laboratory case treatment.
If there are additional laboratory charges incurred they will be the responsibility of the patient and must be paid prior to any additional laboratory treatment.
_______________________________________ _______________________
Printed Name (patient, parent or guardian) Date
_______________________________________
Signature (patient, parent or guardian)
Authorization for Signature on File
Release of Information/Financial Responsibility/Authorization for Payment
I, _________________________________________ and/or _______________________________________
Name of Patient (Parent or Guardian if Minor) Name of Insured
Hereby authorize the office of Right Touch Dental to affix my name to any and all claims or documents as related to any and all health benefits due me and my dependents through my employment with
_____________________________________________________.
Name of employer
I hereby authorize payment of dental benefits otherwise payable to me, directly to the office listed above. I have reviewed the treatment plan and fees. I agree to be responsible for all charges for dental services and materials not paid by my dental benefit plan, unless the treating dentist or dental practice has a contractual agreement with my plan prohibiting all or a portion of such charges. To the extent permitted under applicable law, I authorize release of any information relating to the claim.
THIS “AUTHORIZATION” WILL BE VALID FROM THIS DATE AND SHALL EXPIRE IN ONE YEAR. A PHOTOCOPY OF THIS DOCUMENT MAY ACT AS AN ORIGINAL.
Signature of Insured: ______________________________________________________
Signature of Patient: _______________________________________________________
Parent or Guardian if Minor
Today’s Date: ________________________________
Date:________________________________________
Date:________________________________________
Date:________________________________________
Date:________________________________________
Date:________________________________________
Date:________________________________________
WHITENING SPECIALS
$40 SheerWhite®
Whitening Strips
$150 CUSTOM TRAYS AND ONE TUBE OF WHITENING GEL
$175 CUSTOM TRAYS, ONE TUBE OF WHITENING GEL AND MEDICATED RINSE FOR SENSITIVITY
$350 TWO 15-MINUTE IN OFFICE WHITENING SESSIONS AND MEDICATED RINSE FOR SENSITIVITY
ADDITIONAL TUBES OF WHITENING GEL MAY BE PURCHASED FOR…..
$20 PER TUBE OR $50 FOR THREE TUBES (A $10 SAVINGS)
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PATIENT INFORMATION
Name ___________________________________________________________ SS/HIC/Patient ID #_____________________________
Last Name First Name Middle Initial
Address___________________________________________________________________ E mail________________________________
City___________________________________________________________ State_____________Zip ____________________________
Sex __ M __F Age____________ Birthdate____________________ _____Married _____Widowed _____ Single _____Minor
_____ Separated _____ Divorced ____ Partnered for _____years
Patient Employer/School ________________________________________________ Occupation _____________________________
Employer/School Address _______________________________________________ Employer/School Phone (____)________________
Whom may we thank for referring you?_____________________________________________________________________________
In case of emergency who should be notified? _________________________________________ Phone (_____)___________________
PRIMARY INSURANCE
Person Responsible for Account________________________________________________________________________________
Last Name First Name Middle Initial
Relation to Patient____________________________________ Birthdate______________________ Soc.Sec #______________________
Address (if different from patient’s)___________________________________________________________________________________
City_______________________________________________________ State________________ Zip _______________________
Patient Responsible Employed by___________________________________________________ Occupation _______________________
Business Address ______________________________________________________ Business Phone (____) ____________________
Insurance Company _______________________________________________________________________________________
Contract # _____________________________________ Group# ____________________ Subscriber # ______________
Names of other dependents covered under this plan ______________________________________________________________________
ASSIGNMENT AND RELEASE
I Certify that I, and/or my dependent(s), have insurance coverage with __________________________________________________ and
Name of Insurance Company (ies)
Assign directly to Dr. __________________________________________ all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.
The above-named doctor may use my health care information and may disclose such information to the above-named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
_______________________________________________________________________ __________________________________
Signature of Patient, Guardian or Personal Representative Date
________________________________________________________________________ __________________________________
Please print name of Patient, Guardian or Personal Representative Relationship to Patient
List medications you are currently taking:
______________________________________________________
Pharmacy Name: __________________________________________
Phone (_________) ________________________________________
MEDICATIONS
Physician’s Name ____________________________________________________________________ Date of last visit _________________________________________
Have you ever taken any of the group of drugs collectively referred to as “fen-phen?” These include combinations of lonimin, Adipex, Fastin (brand names of phentermine), Pondimin (fenfluramine) and Redux (dexfenfluramine.) ____Yes _____No
Have you had any serious illnesses or operations? _________________ If yes, describe _____________________________________________________________________
Have you ever had a blood transfusion? ____Yes ____No If yes, give approximate dates _____________________________________________________
(Women) Are you pregnant? _____Yes ____No Nursing? ____Yes _____ No Taking birth control pills? ______Yes ______No
Check (") if you have or haven) Are you pregnant? _____Yes ____No Nursing? ____Yes _____ No Taking birth control pills? ______Yes ______No
Check (√) if you have or have had any of the following:
___Anemia ___Cortisone Treatments ___Hepatitis ___Scarlet Fever
___Arthritis, Rheumatism ___Cough, Persistent ___High Blood Pressure ___Shortness of Breath
___Artificial Heart Valves ___Cough up Blood ___HIV/AIDS ___Skin Rash
___Artificial Joints ___Diabetes ___Jaw Pain ___Stroke
___Asthma ___Epilepsy ___Kidney Disease ___Swelling of Feet or Ankles
___Back Problems ___Fainting ___Liver Disease ___Thyroid Problems
___Blood Disease ___Glaucoma ___Mitral Valve Prolapse ___Tobacco Habit
___Cancer ___Headaches ___Pacemaker ___Tonsillitis
___Chemical Dependency ___Heart Murmur ___Radiation Treatment ___Tuberculosis
___Chemotherapy ___Heart Problems ___Respiratory Disease ___Ulcer
___Circulatory Problems ___Hemophilia ___Rheumatic Fever ___Venereal Disease
MEDICAL HISTORY
Reason for Today’s Visit_______________________________________ Date of last dental care_____________________________
Former Dentist_______________________________________________ Date of last dental X-rays__________________________
Address ____________________________________________________________________________________________________
Check (√) if you have had problems with any of the following
Bad breath Grinding teeth Sensitivity to hot
Bleeding gums Loose teeth or broken fillings Sensitivity to sweets
Clicking or popping jaw Periodontal treatment Sensitivity when biting
Food collection between teeth Sensitivity to cold Sores or growths in your mouth
How often do you floss?______________________________ How often do you brush? _______________________________________
DENTAL HISTORY
ALLERGIES
___Aspirin ____Sulfa
____Barbiturates (sleeping pills) ____Latex
____Codeine ____Other _________
____Local Anesthetic _______________________
____Penicillin
The above information is accurate and complete to the best of my knowledge. I will not hold my dentist or any member of his/her staff responsible for any errors or omissions that I may have made in the completion of this form.
Date__________________________________ Signature _______________________________________________________________
870 Crestmark Drive Suite 100 Lithia Springs, GA 30122
(678) 945-0034 (tel.) (678) 945-0039 (fax)
Dr. Lisa Kimble-Whitmire
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