Backcovedental@1 - New Patient Form

Patient Information
Personal Information
Name*

First NameLast Name
Preferred Name*
Date of Birth*

MonthDayYear
Date
Social Security Number*
Home Phone*
Please enter a valid phone number.
Work Phone
Please enter a valid phone number.
Cell Phone*
Please enter a valid phone number.
If minor, Parent's Names
Mailing Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Email Address*
example@example.com
I would like to receive communication via email
Referred to our office by
Previous Dentist*
Emergency Contact*
Emergency Phone Number*
Please enter a valid phone number.
Insurance Information
Covered by dental insurance?*

YesNo

Rows	Primary Insurance	Secondary Insurance (If applicable)
Subscriber's Name
Relationship to Subscriber
Social Security Number
Date of Birth
Insurance Company
Address
Phone Number
Group Number
ID Number
Employer Name
Employer Address

Payment Methods:
It is our goal for our patients to understand their treatment needs as well as their financial responsibility before treatment begins. Therefore, we offer the following payment options:
1. Flexible payment plans of up to 12 months upon approval with Care Credit. Approval must be received prior to treatment date. Care Credit can be used for treatment over $200.00. Patients can apply online at www.carecredit.com.
2. We accept cash, personal checks, money orders, Visa, Mastercard, Discover, and American Express.
Office Policies:
Patients authorize this office to submit insurance claim forms on their behalf and provide information as needed to their insurance and understand that services offered are his/hers financial responsibility. It is the patient’s responsibility to provide the correct insurance information at each visit. Patients should notify the office as soon as possible if there is a change in their insurance status. Payment in full is required at the time of service for all non-insured patients. Patients are responsible for any outstanding balances regardless of whether they have insurance or not. Insured patients are responsible for their estimated out of pocket costs, any co-pays or deductibles and any balances not covered by insurance at time of service.

Email communications: I am aware that there is some level of risk that third parties might be able to read unencrypted emails. I am responsible for providing the dental practice any updates to my email address. I can withdraw my consent to electronic communications by calling: 207- 773-3794

Broken or missed appointments:
To reschedule or cancel an appointment, please notify us at least 24 hours in advance to avoid a missed appointment fee of $75.00 (fee is based on appointment length and/or number of appointments missed). Broken or missed appointments prevent other patients from receiving the dental care they deserve.

I have read and understand this document in its entirety; outlining our office policies and agree to these terms.
Signature of Patient or Parent/Guardian*

Clear
Date*

MonthDayYear
Date
Notice: Steven S. Shaw D.M.D., P.C., complies with applicable Federal civil rights laws and does not discriminate on the basis of race, color, national origin, sex, or age. If you speak English, the language assistance services are complimentary. (French): Si vous parlez français, des services d'aide linguistique vous sont proposés gratuitement.(Spanish) : si habla español, tiene a su disposición servicios gratuitos de asistencia lingüística.

HIPAA ACKNOWLEDGEMENT FORM
Under the Health Insurance Portability and Accountability Act of 1996 (HIPAA), you have certain rights regarding the use of and disclosure of your protected health information. These rights are more fully described in our Notice of Privacy Practices, updated effective September 23, 2013. Please ask our front desk associate for a copy if you would like one. There is also a framed copy on display in our waiting area.

This information can and will be used to:
- Conduct, plan and direct treatment and follow up care among the multiple healthcare providers who may be involved in the treatment, directly or indirectly.
- Obtain payment from designated third-party payers
You have been given the right to review our Notice of Privacy Practices prior to signing this consent. You understand that Steven S. Shaw DMD P.C. has the right to change its Notice of Privacy Practices from time to time and you may contact us at any time to obtain current copy of the Notice of Privacy Practices.

You may request in writing that we restrict how your private information is used or disclosed to carry out treatment, payment or health care operations. You also understand that Steven S Shaw DMD, P.C., is not required to agree to your requested restrictions, but if Steven S .Shaw DMD, P.C. does agree, then it is bound by such restrictions. You may revoke this consent in writing at any time, except to the extent that Steven S. Shaw DMD, P.C., has taken action relying on this consent.

Please ask our front desk associate for a copy if you would like one. There is also a framed copy on display in our waiting area.

I have received and read this organization’s Notice of Privacy Practices.
Patient Name*
Patient Representative
Date*

MonthDayYear
Date
Date

MonthDayYear
Date
Signature of Patient*

Clear
Signature of Patient Representative

Clear

GENERAL DENTAL TREATMENT CONSENT FORM
It is very important to provide your dentist with accurate information before, during, and after treatment. It is equally important to follow your dentist’s advice and recommendations regarding medications, pre- and post-treatment instructions, referrals to other dentists or specialists, and to return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome. Noncompliant patients may be dismissed from the practice.

I understand that during my course of treatment that the following care may be provided: examinations, preventative services, diagnosis, basic restorative, and crowns. I understand that my initial visit and periodically thereafter, or as needed, I may require radiographs in order to complete the examination, diagnosis, and treatment plan.

I understand that I may receive a local anesthetic and/or other medication. In rare instances, patients may have an unusual reaction to the anesthetic, which may require emergency medical attention, or find that it reduces their ability to control swallowing. This increases the chance of swallowing or aspirating foreign objects during treatment. Rarely, temporary or permanent nerve injury can result from an injection.

I understand that I may experience hot and cold sensitivity, pain, or discomfort following routine restorative procedures and that this is usually temporary and should settle without further treatment. If in the event that my condition does not get any better, I understand that I may need further dental treatment, the most common being root canal therapy, resulting in additional costs. I understand that care must be exercised in chewing on the new filling during the first 24 hours to avoid breakage.

I understand that sometimes it is not possible to match the color of natural teeth exactly with artificial teeth. I further understand that I may be wearing temporary crowns, which may come off easily and that I must be careful to ensure that they are kept on until the permanent crowns are delivered. I realized that the final opportunity to make changes in my new crowns, bridge, or veneer (including shape, fit, size, placement, and color) will be done before cementation. I understand that in very few cases, cosmetic procedures may result in the need for future root canal treatment, which cannot always be predicted or anticipated. I understand that cosmetic procedures may affect tooth surfaces and may

require modification of daily cleaning procedures. General risks include (but are not limited to) complications resulting from the use of dental instruments, drugs, medicines, analgesics (pain killers), anesthetics, and injections. These complications include pain, infection, swelling, bleeding, sensitivity, numbness and tingling sensations in the lip, tongue, chin, gums, cheeks, and teeth; thrombophlebitis (inflammation to a vein), change in occlusion (biting), muscle cramps, and spasms; temporomandibular jaw (TMJ) joint difficulty, loosening of teeth or restoration in teeth, injury to other tissues; and referred pain to the ear, neck and head, nausea, allergic reactions, itching, bruises, delayed healing, sinus complications and further surgery.

I understand that during treatment it may be necessary to change or add procedures because of conditions found while working on the teeth that were not discovered during examination, the most common being root canal therapy following routine restorative procedures. I understand that I have the right to choose, on the basis of adequate information, from alternate treatment plans that meet professional standards of care. I have no further questions.
Patient Signature:*

Clear
Date:*

MonthDayYear
Date
For Office Use Only
We attempted to obtain written acknowledgment of receipt of our Notice of Privacy Practices, but acknowledgment could not be obtained because:

Individual refused to signCommunication barriers prohibit obtaining the acknowledgmentAn emergency situation prevented us from obtaining acknowledgmentOther (Please specify)
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Patient Information

Personal Information

Insurance Information

Medical History

Do you have, or have you had, any of the following?

HIPAA ACKNOWLEDGEMENT FORM

GENERAL DENTAL TREATMENT CONSENT FORM

For Office Use Only