67 smithfield blvd. › ce9fff64 › files... · by providing my email address and mobile phone, i...

THANK YOU for visiting Gentle Touch Family Dentistry! It is our optimal goal to provide you and your family with the highest

quality of dental care while maintaining a friendly and relaxing environment. Please help us by completing this form.

PATIENT INFORMATION

Name

Address

Social Security # Birth Date Emergency Contact

Gender Married Emergency Phone

Home Phone

Mobile Phone

Email Address

Employer: Work Phone

If patient is a student over 19: Institution:

BY PROVIDING MY CONTACT INFORMATION ABOVE, I AUTHORIZE THIS OFFICE TO COMMUNICATE WITH ME ABOUT MY HEALTH,

TREATMENT PLAN, BILLING, AND FINANCIAL OPTIONS.

Check Preferred Contact Method(s):

Please send me appointment reminders by (choose one):

DISCLOSURE OF YOUR HEALTH INFORMATION

Please list any other parties who can have access to your health information. (Disclosure to other parties includes: spouse, children, step

parents, grandparents and any care takers who can have access to your records)

Print name: Relationship: Contact #:



PLEASE PROVIDE INSURANCE CARD TO FRONT DESK.

I HEREBY AUTHORIZE PAYMENT DIRECTLY TO GENTLE TOUCH FAMILY DENTISTRY OF THE GROUP INSURANCE BENEFITS OTHERWISE

PAYABLE TO ME. I UNDERSTAND THAT I AM RESPONSIBLE FOR ALL COSTS OF THE DENTAL TREATMENT.

THE UNDERSIGNED ACKNOWLEDGES RECEIPT OF A COPY OF THE CURRENTLY EFFECTIVE NOTICE OF PRIVACY PRACTICES FOR THIS

HEALTHCARE FACILITY.

Signature Date

IF PATIENT UNDER 18

Responsible Party (print name) Relation to Patient

Address (if different than patient)

STREET CITY STATE ZIP

Electronic (email and/or text message) Mail

FIRST LAST MIDDLE INITIAL NICKNAME

Mobile Phone

Male Female

Work Phone Email Home Phone

Yes No

By providing my email address and mobile phone, I hereby give permission to Gentle Touch Family Dentistry, Dr. Szmigiel and staff, to communicate electronically with me via emails and/or text messages. I am aware and accept the possible risks of receiving electronic information using unencrypted e-mails and text messages.

STREET CITY STATE ZIP

67 Smithfield Blvd. Plattsburgh, NY 12901 P: (518) 324-5555 F: (518) 324-5898 www.gentletouchfamilydentistry.com

Part Time Full Time

OTHER INFORMATION

How did you hear about us?

What was the reason for today’s visi

When was your last dental and hygie

Have you ever been told that you ha

Have you ever noticed your gums bl

Do you love your smile?

Why did you leave your last dentist?

What did you like most about your l

Level of fear coming to the dentist?

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PATIENT MEDICAL HISTORY

Please list all medications that you are currently ta

Is there any disease, condition or problem that you

I certify to the above statements regarding my m

unwanted side effects. You are strongly urged t

your medications.

H H H H H H Im Ja Jo K L L M P P P R R S S S S S S T T U V

CO

Heart Murmur

AL

Other Allergies

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Are you nursing?

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w Pain/Cracking Noise (TMJ) int Replacement idney Problems iver Disease ow Blood Pressure itral Valve Prolapse

ace Maker ostural Problems sychiatric Problems adiation Therapy heumatic Fever eizures exually Transmitted Disease hingles ickle Cell Disease inus Problems troke hyroid Problems uberculosis lcers

NDITIONS

Abnormal Bleeding Alcohol Abuse Anemia Angina Pectoris Arthritis Artificial Heart Valve Asthma Bell’s Palsy Blood Transfusion Cancer Cardiovascular disease Chemotherapy Colitis Congenital Heart Defect COPD Diabetes Difficulty Breathing Drug Abuse Emphysema Epilepsy Facial Pain Fainting Spells Fever Blisters Frequent Headaches Glaucoma HIV + AIDS Heart Attack

king:

have but not covered above?

edical condition. It should be note

o bring to our attention any problem

ertigo

None

No

LERGIES

Aspirin Codeine Dental Anesthetics Erythromycin Latex Metals Penicillin Sulfa Tetracycline

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Female N Are you taking Birth Control Pills?

Are you pregnant? If yes, # of weeks

N Do you Smoke or use Tobacco? Would you like information about


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Patient Name:

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Date:

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Signature

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Pharmacy Location

Thank you for choosing Gentle Touch Family Dentistry for your dental needs. We realize that every person’s financial situation is different. For this reason, we provide a variety of payment options to help you receive the dental care you need and deserve that allows you to enjoy a healthy, beautiful smile with respect to your budget. Dental treatment is an excellent investment in an individual’s medical and psychological care. We are always available to answer your questions or assist you in any way we can.

FINANCIAL POLICY

For patients with insurance coverage, estimated patient portion is required at the time of service.

For patients without insurance coverage, payment in full is due at the time of service. For ease of payment, Gentle Touch offers flexible payment options, please read below.

A specific amount of time has been reserved exclusively for you, if you need to reschedule your appointment, please give our office 48 hours notice to avoid a $40 cancellation fee and allow someone else this time.

Personal checks are accepted for established patients with credit history in good standing. A $35 fee will be charged on returned checks.

You will be responsible for any/all treatment that has been completed. If sent to collections, you agree to pay all related fees and court costs.

INSURANCE POLICY

Our office is committed to helping you maximize your insurance benefits. Because insurance policies vary greatly, we can only estimate your coverage in good faith but cannot guarantee coverage due to the complexities of insurance contracts. Your estimated patient portion must be paid at the time of service. Should your payment exceed the estimated patient portion, at your request, you will be credited the difference. As a courtesy to our patients, insurance claims can be submitted electronically to your insurance company. As such, Gentle Touch will release your information to your insurance company, and may receive payment directly from them. Every effort will be made to help you with your insurance, but if your insurance company fails to pay Gentle Touch as expected within 60 days, you will be responsible for the balance.

PAYMENT OPTIONS

For your convenience, Gentle Touch offers flexible payment options, the following financial arrangements are available to pay for your dental treatment:

Credit and Debit Cards: We accept MasterCard, Visa, Discover and American Express.

Payment Plan: Upon approval, we offer Care Credit, a deferred interest payment plan (up to 12

months) with no down payment, no fees and no prepayment penalty. Long term plans (24-60

months) are also available with interest. Please ask for details.

I ______________________________ have read and accept Gentle Touch Family Dentistry Financial and Insurance Policies

Signature: _________________________________________ Date: ___________

67 Smithfield Blvd. Plattsburgh, NY 12901 P: (518) 324-5555 F: (518) 324-5898 www.gentletouchfamilydentistry.com

GENERAL CONSEN

I hereby authorize the Doctors and/or designated staff to tak

diagnostic aids deemed appropriate by doctor to make a thor

Upon such diagnosis, I authorize the doctor to perform all re

and to employ such assistance as required to provide proper

I agree to the use of anesthetics, sedatives, and other medica

anesthetics agents embodies certain risks. I understand that

complications.

I acknowledge that I have been given full opportunity to dis

information provided.

I understand that dentistry is not an exact science and that th

procedures. I further acknowledge that no guarantee has bee

requested and authorized.

CONSENT FOR USE AND DISCLOSURE OF P

I hereby authorize Gentle Touch Family Dentistry, (hereafteand disclose any oral, written or electronic health records thpurpose of carrying out my treatment, payment and health cNotice of Privacy Practices (NOPP) and Omnibus HIPAA laopportunity to ask questions about it, understand it and do hdated Consent shall be as effective as the original.

I release, hold harmless Gentle Touch Family Dentistry, its arising out of or occurring under this Consent.

Patient Name:

Signature

IF PATIENT UNDER 18

Responsible Party (print name)

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T TO TREAT

e x-rays, study models, photographs, and other

ough diagnosis of my dental needs.

commended treatment mutually agreed upon by me

care.

tions as necessary. I fully understand that using

I can ask for a complete recital of any possible

cuss the treatment plan and that I understand the

ere can be no guarantee of outcome with my dental

n made to me with regard to the procedures I have

ROTECTED HEALTH INFORMATION

r collectively referred to as the “Practice”) to use at are individually identifiable as mine for the are operations in accordance with this Practice’s w. I have reviewed the NOPP, been given an

ereby agree to its terms. A copy of this signed,

employees and agents for any and all liability

Date

Relation to Patient

w.gentletouchfamilydentistry.com

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COVID-19 PANDEMIC - PATIENT DISCLOSURES AND CONSENT

Your health and safety are our primary concern, this disclosure form seeks information from you

that we must consider before making treatment decisions in the circumstance of the COVID-19

virus. Please answer these questions to the best of your ability so that we may help keep you

healthy and safe.

A weak or compromised immune system (including, but not limited to, conditions like diabetes,

asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or

medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any

condition that compromises your immune system and understand that we may ask you to consider

rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID-

19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

Patient Assessment YES NO

Have you experienced flu like symptoms in the last 14 days?

Do you have a fever or above normal temperature?

Have you had fever in the last week?

Have you experienced shortness of breath or had difficulty breathing?

Do you have a dry cough?

Do you have a muscle pain?

Have you recently lost or had a reduction in your sense of taste or smell?

Do you have a sore throat?

Do you have persistent pain or pressure in the chest?

Have you come in close contact with anyone who has displayed or is currentlyexperiencing any of symptoms listed above in the last 14 days?

Have you been in contact with someone who has tested positive for COVID-19 in the past 14 days?

Have you tested positive for COVID-19?

Have you been tested for COVID-19 and are awaiting results?

Patient Travel YES

Have you travelled inside or outside the United States by plane in the last 14 days?

Have you traveled within the United States by air, bus or train within the past 14 days?

Have you been on a cruise in the last 14 days?

Have you attended large events and mass gatherings in the last 14 days?

Have you been in contact with anyone who has returned in the last 14 days from traveling to any of the countries or regions with widespread ongoing transmissions, including all European countries, China, Korea, and Latin America?

NO

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Patient Medical Condition YES NO

Do you have any of the following medical conditions?

Chronic Obstructive Pulmonary Disease (COPD)

Any lung conditions

Any heart conditions

Diabetes

Cancer treatment, radiation, chemotherapy

Immunocompromised

I fully understand and acknowledge the above information, risks and cautions and have disclo

my provider any conditions in my health history which may result in a compromised immune

system.

Furthermore, I understand the potential risks, complications and side effects involved with an

dental treatment or procedure and have decided to proceed after considering the possibility o

both known and unknown risks including the potential risk for contraction of the Coronavirus

Moreover, given that dentistry involves close interpersonal contact and the production of aer

I understand that there is an elevate risk of contracting the coronavirus simply by being in the

dental office.

I declare that I have had the opportunity to ask questions and all of my questions have been

answered to my satisfaction.

By signing this document, I acknowledge that the answers I have provided above are true and

accurate.

Signature: Date:

IF PATIENT UNDER 18


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Patient Name:

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COVID-19 PANDEMIC EMERGENCY DENTAL TREATMENT NOTICE AND ACKNOWLEDGEMENT OF RISK, RELEASE OF CLAIMS FORM

I, (the patient), consent to receive emergency treatment from Gentle Touch Family Dentistry (the Practice) during the COVID-19 outbreak.

Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the COVID-19 virus.

The COVID-19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID-19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting COVID-19 associated with dental care.

The COVID-19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID-19 is challenging and complicated due to limited availability for virus testing.

Based on what is currently known about COVID-19, the spread is thought to occur mostly from person-to-person via respiratory droplets during close contacts. I understand that close contact can occur from being within approximately 6 feet (or more) of someone with COVID-19 for a period of time, or by having direct contact with infectious secretions from someone with COVID-19.

Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

Dental procedures create water spray which is one way the disease is spread. The ultra-fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID-19 virus to those nearby.

You cannot wear a protective mask over your mouth to prevent infection during treatment as your health care providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.

Pursuant to statements from the Center for Disease Control (CDC) and the American Dental Association (ADA), non-essential or elective treatment, based on the assessment of our staff, will be rescheduled. According to the ADA, dental emergencies are “potentially life threatening and require immediate treatment to stop ongoing tissue bleeding [or to] alleviate severe pain or infection.” The ADA also recommends that urgent dental care which “focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments” be provided in as minimally invasive a manner as possible.

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I understand that even if all the CDC and ADA guidelines for infection control of COVID-19 are followed, I can still be at risk for possible infection of the COVID-19 virus.

I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID-19 virus in the dental office or with dental treatment. I further confirm I am seeking treatment for a condition that meets the emergent or urgent criteria noted above. I understand and accept the additional risk of contracting COVID-19 from contact at this office. I also acknowledge that I could contract the COVID-19 virus from outside this office and unrelated to my visit here.

RELEASE OF CLAIMS

I release, give up and forever relinquish any and all claims, complaints and any legal actions in any

court of law, or in any other proceedings before any governmental entity, that I became infected

with the coronavirus, or that I suffered any other personal, physical or any other injury as a result of

the emergency dental treatment I have received from Gentle Touch Family Dentistry and from all

the professional and providers who treated me. I understand this release means that I can never

bring any claim for any money damages, nor for any other legal remedy/relief against Gentle Touch

Family Dentistry, its employees and agents. I acknowledge that I have read and understand this

Release and that I knowingly and voluntarily have signed it as a condition of the Practice agreeing to

provide emergency treatment for me.

Signature: Date:

IF PATIENT UNDER 18


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