Adult Dental Clinic Registration

    Patient Contact Information

    Emergency Contact

    Primary Dental Insurance Policy

    Secondary Dental Insurance Policy

    Dental and Medical Background

    Dental History: Please mark yes or no to indicate if you have had any of the following:

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    Medical History: Please mark yes or no to indicate if you have had any of the following:

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    Medications

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    Allergies

    Are you allergic to any of the following:

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    Consent:

    The information in this health history is correct to the best of my knowledge.

    I understand the Risks and Benefits of receiving oral health care, listed below:
    Risks of not receiving treatment – gum disease, tooth and bone loss, late detection of oral cancers
    Benefits of receiving treatment – gum disease prevention; decrease in bacterial load with reduced chance for heart attack, stroke, and cardiovascular disease; detection of oral cancers that are curable at an early stage

    I understand that the treatment I will receive can include: internal and external evaluation and cancer screen, radiographs (x-rays) for the purpose of diagnosing dental hygiene related conditions and identifying dental abnormalities for referral, dental hygiene diagnosis of periodontal health (bone and gum health), dental hygiene treatment planning for dental hygiene services, fluoride treatments, and oral hygiene instruction.

    I understand that for the sustainability of the program, my insurance will be billed. I request and authorize the release of any information on this form and acquired in the course of treatment for payment & referral purpose as deemed necessary by TCHNetwork. I authorize TCHNetwork to submit claims to my insurance company on my behalf, and my insurance company to pay benefits directly to TCHNetwork. Should any payment be made directly to the insured for monies due on this account, I agree to immediately pay over these funds to TCHNetwork. I authorize TCHNetwork to complete the above services for the benefit of my oral health care.

    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. By signing this consent form, I authorize TCHNetwork to use and disclose my protected health information to:

    • Perform treatment, this includes direct or indirect treatment by other healthcare providers involved in my treatment
    • Obtain payment from third party payers such as my insurance company
    • Carry out daily healthcare operations of this clinic

    I have been informed of and given the right to review and secure a copy of TCHNetwork’s Notice of Privacy Policy which contains a more complete description of the uses and disclosures of my protected health information and my rights given to me by HIPAA. I understand that TCHNetwork reserves the right to change the terms of this notice and that I may contact TCHNetwork at any time to obtain the most current policy.

    I understand that I have the right to request restrictions upon how my protected health information is used and disclosed for the above listed purposes, and that TCHNetwork is not required to agree to such requests. If requests are agreed upon between myself and TCHNetwork, then THCNetwork is bound to comply with my requested restrictions.

    I understand that I may revoke this consent at any time, in writing. Any uses or disclosures of protected health information that occurred before the date of my revocation will not be affected.

    In the event of an emergency, my emergency contact, listed above, may access my dental records.

    By signing this release, I am acknowledging that all diagnosis and assessment provided by Tri-County Health Network Registered Dental Hygienist is for the purpose of determining necessary dental hygiene services only. It is recommended by the American Dental Association or any successor organizations that a thorough dental examination be performed by a dentist twice each year.

    Sign and submit to provide consent:

    *use mouse or cursor to sign name

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