Title Page
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First and Last Name:
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Date:
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Phone:
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Street:
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City:
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State:
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Zip Code:
Dental Clinic Policies
Dental Clinic Policies:
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1. Denti-Cal/Medi-Cal may require Pre- Approval. Approvals may take up to 6 weeks. We will inform you once received.
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2. All patients must have Valid form of ID and an active insurance card.
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3. All non- covered benefits must be paid in full prior to beginning treatment.
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4. Payments plans are available- Please ask the front desk for information.
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5. Multiple office visits may be required based on your treatment.
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6. Active treatment plan is based on symptoms, current clinical evaluation, dental x-rays and an independent doctor diagnosis.
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7. ONLY the patient is allowed in the treatment room- applies to ALL patients.
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8. All patients will be charged $35 for dental records including x-ray's emailed to the patient OR different dental offices.
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9. All Debit/Credit card transactions are subject to a 3% convenience fee.
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Please Sign Below if You Agree to the Above
Informed Consent
Informed Consent:
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1.A. Arbitration Arbitration is the final process for the resolution of any dispute or controversy between a patient, or a personal representative of the patient as the case may be, and Nor-Cal Dental /Bhogal Dental Group concerning the quality of patient services provided to a patient under this agreement for any dispute or controversy concerning the construction, interpretation, performance or breach of this agreement. By entering into this agreement, the patient agrees that such disputes shall be submitted to binding arbitration under the appropriate rules of the American Arbitration Association (AAA). I. Patient understands and agrees that any and all disputes between patient and Nor-Cal / Bhogal Dental group or its providers shall be resolved by submission to binding arbitration conducted by the AAA. Such Disputes or controversies include, but are not limited to complaints concerning the quality, necessity or outcome of services provided pursuant to this Informed Consent Form, as well as the construction, interpretation, performance or breach of the terms of this Informed Consent Form. II. Patient further recognizes that by consenting to binding arbitration, patient is giving up the right to have such disputed decided in a court of law and/or before a jury. A declaration of a court or other tribunal of competent jurisdiction that any portion of this agreement to arbitrate is void or unenforceable shall not render any other provision hereof void or unenforceable. B. INITIATION OF ARBITRATION: Arbitration can be initiated by filling a demand for arbitration with the AAA, located at 225 Bush Street, San Francisco, CA 94104-4207, Telephone number (415) 981-3901. A demand form may be obtained from the AAA. C. COSTS: In all arbitration matters submitted to the AAA, the party initiating demand for the arbitration shall advance all administrative fees connected therewith. D. LOCATION: Arbitration proceedings shall occur in the county where the patient’s treatment was performed, unless all parties to the arbitration otherwise agree in writing. E. FORM OF DECISION: The parties agree that the arbitrators shall issue a written opinion. The award of the arbitrators shall be binding and may be enforced in any court having jurisdiction thereof by filing a petition of enforcement of said award. The arbitrator’s award shall be accompanied by a written decision explaining the facts and reasons upon which the award is based, including the findings of fact and conclusions of law made and reached by the arbitrator.
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2. WORK TO BE DONE: I understand that the following procedures may be performed on me as part of my dental treatments: X-rays, Fillings, Bridges, Crowns, Extractions, Impacted Teeth Removal, Root Canals, Dentures, Partial Dentures, Periodontal Treatments and possible other dental treatments.
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3. FILLINGS: Fillings are procedures in which the dentist removes decayed tooth structure or a faulty restoration and replaces it with Composite Resin or Silver Amalgam fillings. I understand that these procedures could cause the teeth to be sensitive to hot and cold as well as chewing. The majority of the time, these sensitivities are temporary, and they will go away within one (1) or two (2) weeks. However, there are times that due to the depth of the filling in the tooth, the pulp or the nerve of the tooth becomes irreversibly sensitive. In these cases, the tooth will need to be treated for root canal therapy and might possibly require a post and a crown to be fully restored. I understand that the dentist cannot guarantee that the teeth receiving fillings will not need to receive the above-mentioned additional procedures and that I will be responsible for payments for any additional treatments needed to restore the teeth, if the initial filling procedure does not correct the problem.
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4. DRUG AND MEDICATIONS: I understand that antibiotics, analgesics and other medication can cause allergic reactions causing redness and swelling of tissues, pain, vomiting and/or anaphylactic shock (severe allergic reaction).
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5. CHANGES IN TREATMENT PLAN: I understand that during treatment it may be necessary to change procedures because of conditions found while working on the teeth that were not discovered during examination. I give my permission to the Dentist to make those changes as necessary.
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6. REMOVAL OF TEETH: Alternatives to removal have been explained to me (root canal therapy, crowns and periodontal surgery, etc.) and I authorize the Dentist to remove the teeth outlined in the treatment plan and any others necessary under paragraph #5. I understand removing teeth does not always remove all the infection, if present, and it may be necessary to have further treatment. I understand the risk involved in having teeth removed, some of which are pain, swelling, spread of infection, dry socket, loss of feeling in my teeth, lips, tongue and surrounding tissue (Paresthesia) that can last for an indefinite period of time (days or months) or fractured jaw. I understand I may need further treatment by a specialist or even hospitalization if complications arise during or following treatment.
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7. ANESTHESIA: I realize the risks involved in receiving a local anesthetic, some of which are facial paralysis, inflamed tissue, adverse reactions to drugs causing cardiac arrest, miscarriage, hemorrhage, nerve damage and/or numbness. I also understand in rare instances patients may have allergic reactions to anesthetic, which may require emergency medical attention, or find that anesthesia reduces the ability to control swallowing, which increases the chance of swallowing foreign objects during treatment.
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8. CROWNS, BRIDGES AND CAPS: 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, and that if I don’t have the permanent crown(s) placed, permanent serious damage or loss of the tooth/teeth involved may ensue, and that if I delay placement I may cause the teeth involved to move making the permanent crown not fit properly. I also understand the lower edge of a crown is usually designed to rest near the gumline, which may increase the chance of gum irritation, infection or decay. Proper brushing and flossing at home, a healthy diet and regular professional cleanings are essential to help prevent these problems.
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9. DENTURES–COMPLETE OR PARTIAL: I realize that full or partial dentures are artificial, constructed of plastic, metal and/or porcelain. The problems of wearing these appliances have been explained to me including looseness, soreness, and possible breakage, and relining due to tissue and bone change.
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10. ENDODONTIC TREATMENT (ROOT CANAL): I realize there is no guarantee that root canal treatment will save my tooth, and that complication can occur from treatment. Occasionally a root canal instrument will break off in a root canal that is twisted, curved or blocked with calcium deposits. Depending on its location, the fragment can be retrieved, or it may be necessary to seal it in the root canal (these instruments are made of sterile, non-toxic surgical steel, so this causes no harm). It may also be necessary to perform an apicoectomy to seal the root canal. As a result of filing in the root canal, the incomplete formation of your tooth, or an abscess at the end of the tooth (called the apex), an opening may exist between the root canal and the bone or tissue surrounding the tooth. This opening can allow filling material to be forced out if the canal into the surrounding bone and tissue. An apicoectomy may be necessary for retrieving the filling material and sealing the root canal. Teeth that receive root canal treatment may be more prone to cracking and breaking over several years’ time, which may ultimately require a bridge or partial denture.
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11. PERIODONTAL (TISSUE AND BONE) TREATMENT: I understand that I have a serious condition, causing gum and bone inflammation or bone loss and that it can lead to the loss of my teeth. The alternative treatment plans have been explained to me, including gum surgery, replacements and/or extractions. I hereby request and authorize the Dentists and their staff, to perform dental work upon me for the purpose of attempting to improve my appearance, function and the health of my mouth, teeth, bone and tissues, as explained above. The effect and nature of the proceeding to be performed, and the risks involved, as well as the possible alternative methods of treatment have been fully explained to me. I also authorize the operating Dentist and Assistants to perform any other procedure which they may deem necessary or desirable in attempting to improve the condition stated on the diagnostic treatment form, or treat unhealthy or unforeseen conditions that may be encountered during the operation. I know that the practice of Dentistry and surgery is not an exact science and that therefore reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the treatment which I have herein requested and authorized. Alternatives and possible bad reactions have been explained to me in detail. Complications, such as infection, hemorrhage and/or bleeding, scarring, contraction, possible deformities, prolonged healing time over the estimate, reaction to any drugs before, during and after surgery, numbness or itching of the tongue, lip, teeth, tissues, (Paresthesia), fractured jaw, Temporomandibular Joint (TMJ) Complication, which could cause localized and systemic pain requiring future treatments including joint surgery, etc., have been clearly explained to me.
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CONSENT FOR CONSULTATION AND CARE: I hereby request and authorize the Dentists and dental staff, to perform dental work upon me for the purpose of attempting to improve my appearance, function and the health of my mouth, teeth, bone and tissues, as explained above. The effect and nature of the proceeding to be performed, and the risks involved, as well as the possible alternative methods of treatment have been fully explained to me. I also authorize the operating Dentist and Assistants to perform any other procedure which they may deem necessary or desirable in attempting to improve the condition stated on the diagnostic treatment form or treat unhealthy or unforeseen conditions that may be encountered during the operation. I know that the practice of Dentistry and surgery is not an exact science and that therefore reputable practitioners cannot properly guarantee results. I acknowledge that no guarantee or assurance has been made by anyone regarding the treatment which I have herein requested and authorized. Alternatives and possible bad reactions have been explained to me in detail. Complications, such as infection, hemorrhage and/or bleeding, scarring, contraction, possible deformities, prolonged healing over time the estimate, reaction to any drugs before, during and after surgery, numbness or itching of the tongue, lip, teeth, tissues, (paresthesia), fractured jaw, Temporomandibular Joint(TMJ) Complications, which could cause localized and systemic pain requiring future treatments including joint surgery, etc.., have been clearly explained to me.
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CONSEQUENCES OF NOT PERFORMING TREATMENT: This course of treatment will help to relieve your symptoms. If no treatment were performed, you would continue to experience symptoms, which could include pain and/or infection, deterioration of the bone surrounding your teeth, changes to your bite, discomfort in your jaw joint and possibly the premature loss of these and other teeth. Every reasonable effort will be made to ensure that your condition is treated properly, although it is not possible to guarantee perfect results. By signing below, you acknowledge that you have received adequate information about the proposed treatment, that you understand this information and that all of your questions have been answered fully.
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I CERTIFY THAT I HAVE READ AND FULLY UNDERSTAND THE ABOVE CONSENT TO DENTAL TREATMENT AND THAT THE EXPLANATIONS THEREIN REFERRED TO WERE MADE. ANYTHING I DID NOT UNDERSTAND HAS BEEN EXPLAINED TO ME.
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PATIENT / PARENT / RESPONSIBLE PARTY SIGNATURE
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WITNESS SIGNATURE
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DOCTOR SIGNATURE
Payment Arrangement
Payment Arrangement
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I agree that I am responsible for all services rendered to the Patient and that payment is due and payable to the Practice at the time services are rendered and that health, dental and accident insurance policies are an arrangement between my insurance carrier and me. I agree to pay all deductibles and co-pays at the time of service (if I have dual insurance coverage, my co-pay or deductible will be based on the primary coverage). I understand that while the Practice will file claims with my insurance company on my behalf, I remain responsible to the Practice for what is not paid by my insurance company. I also understand that if the Practice cannot verify insurance benefits eligibility for me prior to treatment that I will pay in full for the services at the time they are rendered. I understand that the Practice may charge: 1) a late fee if payment on my account is not received by the due date; 2) an amount equal to $35.00, but not to exceed the maximum amount permitted by law for each returned check, and 3) a fee for each appointment that is missed/canceled without at least 24 hours advance notice. I understand that if treatment or care is suspended at any time by the patient, all fees for professional services rendered will be immediately due and payable. I authorize payment directly to the Practice. I understand if I have an unpaid balance to NorCal Dental Group and do not make satisfactory payment arrangements, my account may be placed with an external collection agency. I will be responsible for reimbursement of the fee of any collection agency, which may be based on a percentage at a maximum of 35% of the debt, and all costs and expenses, including reasonable collection and attorney’s fees incurred during collection efforts. In order for NorCal Dental Group or their designated external collection agency to service my account, and where not prohibited by applicable law, I agree that NorCal Dental Group and the designated external collection agency are authorized to (i) contact me by telephone at the telephone number(s) I am providing, including wireless telephone numbers, which could result in charges to me, (ii) contact me by sending text messages (message and data rates may apply) or emails, using any email address I provide and (iii) methods of contact may include using pre-recorded/artificial voice message and/or use of an automatic dialing device, as applicable. Furthermore, I consent to the designated external collection agency to share personal contact and account related information with third party vendors to communicate account related information via telephone, text, e-mail, and mail notification.
Responsible Party
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Full Name:
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DOB:
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SSN#:
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Street Address:
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City:
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State:
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Zip:
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Home Phone:
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Work Phone:
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Employer Name:
Insurance Information
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Primary Insurance Name:
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Address:
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Phone Number:
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Name of Insured:
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Relationship:
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ID Number:
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Group Number:
Emergency Contact
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Name:
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Relationship:
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Phone Number:
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Address:
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City:
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State:
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Zip:
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Signature of Responsible Party
Patient HIPAA Consent Form
Patient HIPAA Consent Form
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I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out: Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment); Obtaining payment from third party payers (e.g. my insurance company); The day-to-day healthcare operations of your practice.
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I have also been informed of and given the right to review and secure a copy of your Notice of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.
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I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these requested restrictions. However, if you do agree, you are then bound to comply with these restrictions.
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I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.
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Signature:
Dental History
Are any of your teeth sensitive to:
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Hot or cold?
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Sweets?
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Biting or chewing?
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Have you noticed any mouth odors or bad taste?
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Do you frequently get cold sores, blisters or any other oral lesions?
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Do your gums bleed or hurt?
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Have your parents experienced gum disease or tooth loss?
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Have you noticed any loose teeth or change in your bite?
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Does food tend to become caught in between your teeth?
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where?
Do you:
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Clench or grind your teeth while awake or asleep?
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Bite your lips or cheeks regularly?
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Hold foreign objects with your teeth (pencils, pipe, pins, nails, fingernails)?
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Mouth breathe while awake or asleep?
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Have tired jaws, especially in the morning?
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Snore or have any other sleeping disorders?
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Smoke/chew tobacco or use other tobacco products?
Have you ever had:
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Orthodontic treatment?
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Oral surgery?
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Periodontal surgery?
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Your teeth ground or the bite adjusted?
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A bite plate or mouth guard?
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A serious injury to the mouth or head?
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please describe, including cause
Have you experienced:
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Clicking or popping of the jaw
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Pain (joint, ear, side of face)?
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Difficulty in opening or closing the mouth?
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Difficulty in chewing on either side of the mouth?
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Headaches, neck aches or shoulder aches?
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Sore muscles (neck shoulders)?
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Are you satisfied with your teeth's appearence?
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Would you like to keep all your teeth all your life?
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Do you feel nervous about having dental treatment?
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If so, what is your biggest concern?
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Have you ever had an upsetting dental experience?
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if yes, please describe
Medical History
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Physician's Name:
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Phone:
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Have you had any medical care within the past two years?
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Describe
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Have you had any medication or drugs during the past two years?
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Are you currently taking any medication, drugs, pills, or herbal remedies, including regular dosage of aspirin?
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Have you ever taken prescription medications for weight loss (diet pills)?
Did you take any of the following?
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Fen-Chen
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Pondimen
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Redux
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Other
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If you answered to any of the above, did you have a medical exam for heart issues?
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Have you ever taken bone loss prevention drugs such as Fosamax, Actonel, Boniva, or other similar drugs?
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Are you aware of having an allergic (or adverse) reaction to any substance or medication?
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Please specify:
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Have you been a patient in the hospital during the past five years?
Indicate which of the following you have had, or have at present. Check "Yes" or "No" to each item.
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Heart (Surgery, Disease, Attack)
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Chest Pain
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Congenital Heart Disease
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Heart Murmer
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High/Low Blood Pressure
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Mitral Valve Prolapse
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Artificial Heart Valve/Pacemaker
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Rheumatic Fever
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Arthritis/Rheumatism
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Cortisone Medicine
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Swollen Ankles
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Stroke
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Diet (Special/Restricted)
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Artificial Joints (Hip, Knee, etc.)
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Kidney Trouble
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Ulcers
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Diabetes
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Thyroid Problems
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Glaucoma
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Contact Lenses
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emphysema
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Chronic Cough
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Tuberculosis
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Asthma
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Hay Fever/Allergy/Hives
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Latex Sensitivity
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Sinus Trouble
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Radiation Therapy
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Chemotherapy
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Tumors
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Hepatitis A,B,C
- A
- B
- C
- N/A
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Veneral Disease
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AIDS/HIV Disease
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Cold Sores/ Fever Blisters
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Blood Transfusion
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Hemophilia
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Sickle Cell Disease
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Bruise Easily
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Liver Disease/Yellow Jaundice
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Neuroligical Disorders
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Epilepsy or Seizures
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Fainting or Dizzy Spells
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Nervous/Anxious
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Psychiatric/Psychological Care
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Have you lost or gained more than 10 pounds in the last year?
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Do you have or have you had any disease, condition, or problem not listed?
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Women: Are you pregnant or think you could be pregnant?
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Do you use birth control prescriptions?
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Patient/Guardian Signature
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Dentist Signature
