• How did you hear about our office?*

  • Patient Information

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  • Is the Patient Also the Responsible Party?*
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  • Medical History

  • Have you ever had any of the following problems? Please select all that apply*

  • Do you have High Blood Pressure*
  • Are you being treated by a physician?*
  • Are you allergic to any of the following:*
  • Do you snore/have you been told that you snore?*
  • Do you grind or clench your teeth at night?*
  • Do you sleep well throughout the entire night?*
  • Do you feel rested throughout the day?*
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  • Are you currently on any medications?*

  • Dental Health

  • To make our patients comfortable we offer several amenities. Select all that Apply*

  • Smile Analysis

  • Are you unhappy with the overall appearance of your teeth, your smile?*
  • Do you consider your teeth discolored, yellow or dark?*
  • Would you like your teeth to be whiter?*
  • Do you have any existing dental work you find unattractive?*

  • The above information is correct to the best of my knowledge and I authorize the doctor and staff to provide dental services including photographic documentation for scientice and educational purposes.  I assume responsibility for fees associated with all services provided. 

  • NOTICE OF PRIVACY PRACTICES SUMMARY

    This notice is a summary of how your protected health information is used and disclosed and how you can obtain access to this information. Please see the front desk to review a full copy of our Notice of Privacy Practices.

    Uses and Disclosures of Health Information

    We use health information about you for treatment, to obtain payment for treatment, for administrative purposes, and to evaluate the quality of care that you receive.  We may use or disclose identifiable health information about you without your authorization for several other reasons.

    Subject to certain requirements, we may give out health information without your authorization for public health purposes, for auditing purposes, for research studies, and for emergencies. We provide information when otherwise required by law, such as for law enforcement in specific circumstances. In any other situation, we will ask for your written authorization before using or disclosing any identifiable health information about you. If you choose to sign an authorization to disclose information, you can later revoke that authorization to stop any future uses and disclosures.

    We may change our policies at any time. Before we make a significant change in our policies, we will change our notice and post the new notice in the waiting area. You can also request a copy of our notice at any time. For more information about our privacy practices, contact the person listed below.

    Your Rights

    Although your health record is the physical property of the healthcare practitioner or facility that compiled it, the information belongs to you. You have the right to:

    • request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.522
    • obtain a paper copy of the notice of privacy practices upon request
    • inspect and obtain a copy of your health record as provided for in 45 CFR 164.524
    • amend your health record as provided in 45 CFR 164.528
    • obtain an accounting of disclosures of your health information as provided in 45 CFR 164.528
    • request communications of your health information by alternative means or at alternative locations
    • revoke your authorization to use or disclose health information except to the extent that action has already been taken

     Complaints

    If you are concerned that we have violated your privacy rights, or you disagree with a decision we made about access to your records, you may contact the person listed below. You also may send a written complaint to the U.S. Department of Health and Human Services. The person listed below can provide you with the appropriate address upon request.

     Our Legal Duty

    We are required by law to protect the privacy of your information, provide this notice about our information practices, and follow the information practices that are described in this notice.  If you have any questions or complaints, please contact: Practice Coordinator at (501)821-4200 or email info@smilearkansas.com

     WRITTEN ACKNOWLEDGEMENT

     I acknowledge that I have reviewed the Notice of Privacy Practices which provides a description of information uses and disclosures. I understand that I have the right to request restrictions as to how my health information may be used or disclosed and that the organization is not required to agree to the restrictions I request.

  • Date*
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    2 digit month, 2 digit day, 4 digit year

  • What to Expect on Your First Visit

    First, you will be welcomed and given a short tour of the office. The Practice Coordinator will assist you in filling out your medical history if needed. She will also want to get to know you, how we can help you and answer any questions you may have. We realize that no two patients are alike and everyone has different goals and aspirations. Our goal is to help you get what you want! She will then introduce you to our dental hygienist, dental assistant or Dr. Wyant depending on the type of appointment you have.

    We offer three types of appointments for new patients at Smile Arkansas. The type of visit generally scheduled for you is determined by asking you a series of questions during your initial phone contact with the office. To satisfy your exact needs we offer:

    • Comprehensive Examination – We will review your medical history, take any necessary photos or x-rays, provide oral cancer screening, periodontal (gum) evaluation and a dental health assessment. We will also address any other concerns you may have such as cosmetic, orthodontic, TMJ, bite issues, missing teeth, pain or sensitivity, etc. If you’d like, we can also arrange to have the hygienist clean your teeth the first visit if scheduled in advance.
    • Problem Focused Examination – If you’re experiencing a specific problem you want addressed, Dr. Wyant will evaluate the issue, provide a diagnosis and recommend a course of action.
    • Free Consultation- If you are uncertain about a current dental situation and need some guidance, a consultation may be in order. Dr. Wyant will meet with you and answer any questions you may have. Though general treatment recommendations can be given, specific recommendations and fees can’t be given until a thorough examination has been done.

    Financial Policy / Dental Insurance

    Our office is a fee for service practice and payment is usually due at the time of service unless prior arrangements have been made. We accept Visa, MasterCard, Discover, American Express, cash or checks. We also have several financing options available. We will work with you so you can have the care you want within your budget. For patients with dental insurance, we will provide a free benefits review to help you maximize your benefits. We will file all claims for you and provide follow up or appeals as needed. Your insurance company will make re-imbursements directly to you depending on your coverage as outlined by your insurance policy. We will always offer you the best care available regardless of the limitations imposed by your insurance coverage. Though we are not in any network, our patients choose to see us out of network because receiving care outside of the restrictive network contracts gives patients the best options for the quality care they want.

    Follow-up Appointments

    If a diagnosis and treatment recommendations are fairly simple and straight forward and the schedule allows, you will be given the opportunity to have treatment that same day. If not, an appointment for treatment can be made and at your earliest convenience. If you have dental insurance, the Practice Coordinator will help determine your benefits, go over fees and help with payment plans if needed. If your treatment is more involved, Dr. Wyant may recommend a follow up planning appointment giving him time to develop a treatment plan based on your dental goals. He may offer different options for care and help you decide what is best for you. Spouses are always welcome to this planning appointment.

    Appointment Policy

    It is very important that we receive notice of a change in your appointment plans at 2 business days in advance.  This gives us the chance to schedule another patient in your place.  If we do not have sufficient notice regarding a schedule change, we will be unable to care for another patient in need of our services.

    Smile Arkansas Dental Office is sure that you understand why we must have policies along these lines.   It is our policy to charge a $ 50.00 missed appointment fee to any patient that cancels their appointment without a 2 business day warning

    I understand that by signing this agreement I am expected to adhere to the all the above policies set forth within this notice.

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