top of page
Patient Information
Chart # _______
(for office use only)

Preferred Appointment time: 

Address: 

Health Information 

Date of Last Visit: 

Reason for this visit: 

Do you have any of the following? 

Please check those that apply.

Select all that applies
Select all that applies
Select all that applies
Select all that applies

Have you had complications following dental treatment?

If yes, please explain:

Have you been admitted to a hospital or needed emergency care during the past two years?

If yes, please explain:

Are you under the care of a physician?

If yes, please explain:

Name of Physician:

Phone Number:

Do you have any health problems that need further clarification?

If yes, please explain:

To the best of my knowledge, all of the preceding answers and information provided are true and correct.  If I ever have any change in my health, I will inform the doctors at the next appointment without fail. 

Address: 

Referral Information 

Whom may we thank for referring you to our practice ?

Name of person or office referring you to our practice:

(CONTINUE TO NEXT PAGE)

Spouse or Responsible Party Information

The following is for: 

Address: 

Employment Information

The following is for: 

Employer Name:

Occupation:

Address: 

Insurance Information

Primary
Name of Insured: 

Is insured a patient?

Insured's Birth Date: 

ID #:

GroupID #:

Insured's Address: 

Patient's relationship to insured:

Insurance Plan Name and Address:

Secondary
Name of Insured: 

Is insured a patient?

Insured's Birth Date: 

ID #:

GroupID #:

Insured's Address: 

Patient's relationship to insured:

Insurance Plan Name and Address:

Consent for Services

As a condition of treatment by this office, financial arrangements must be made in advance.  The practice depends upon reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment.

all emergency dental services, or any dental service performed without previous financial arrangements, must be paid for in cash at the time services are performed.

Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient and that he or she is personally responsible for payment of all dental services.  This office will help prepare the patients insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.

A service charge of 1.5% per month (18% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied. 

I understand that the fee estimate listed for this dental care can only be extended for a period of six months from the date of the patient examination.

In consideration for the professional services rendered to me, or at my request, by the Doctor, I agree to pay therefore the reasonable value of said services to said Doctor, or his assignee, at the time said services are rendered, or within five (5) days of billing if credit shall be extended.  I further agree that the reasonable value of said services shall be billed unless objected to, by me, in writing, within the time for payment thereof.  I further agree that a waiver of any breach of any time or condition hereunder shall not constitute a waiver of any further term or condition and I further agree to pay all costs and reasonable attorney fees if suit be instituted hereunder. 

I grant my permission to you or your assignee, to telephone me at home or at my work to discuss matters related to this form. 

I have read the above conditions of treament and payment and agree to their content. 

Relationship to Patient:

Relationship to Patient:

(CONTINUE TO NEXT PAGE)

HOMELAND AVENUE DENTISTRY

Patient Authorization Form


This form required by health insurance Portability and Accountability Act of 1996 in compliance with the privacy regulation effective for this office on April14, 2003. Only if our office wishes to use or disclose your protected health information for any other purpose not clearly spelled out in our office Privacy Policy Notice.

To use or disclose your protected health information in such cases, our office must receive prior written authorization from you, the patient. Our office may not condition treatment, payment, enrollment or eligibility for benefits on whether you sign this authorization. The purpose for which our office is requesting your authorization is as follow:
 
For permission to contact your insurance companies for payment and prior approval of dental work if needed. The information to be disclose would be as follows:
For dental work only
The information will be disclosed to the following entity:
For referrals to Dental Specialists and Physicians insurance payment centers

By agreeing to this authorization, you understand that the potential for information disclosed pursuant to this authorization may be subject to re disclosure by the recipient and no longer protected by the privacy regulation of HIPPA. You also understand that you are entitled to receive a copy of this authorization form.

I                                                       , gives my authorization to Dr Christopher Clark and Associates for the purpose stated above. I understand that I can revoke this authorization at any point in the future by submitting written notice to Dr Christopher Clark.
. 

(CONTINUE  TO NEXT PAGE)

HOMELAND AVENUE DENTISTRY

Appointments 


EFFECTIVE IMMEDIATELY
 

  • ALL APPOINTMENTS MUST BE CONFIRMED WITHIN 24 HOURS PRIOR TO SCHEDULE DATE OR IT WILL BE CANCELLED!

    PATIENTS MUST CALL 24 HOURS IN ADVANCE TO CANCEL/RESCHEDULE APPOINTMENT TO AVOID A $25.00 CHARGE.

    AFTER 2 MISSED/NO SHOW APPOINTMENTS WITHOUT 24 HOUR NOTICE YOU WILL BE PUT ON WALK IN STATUS ONLY. AFTER THE 3RD MISSED/NO SHOW WILL RESULT IN PATIENT DISMISS    AL FROM THE PRACTICE.

    ALL CO-PAYMENTS ARE DUE AT TIME OF SERVICE 

    ALL OUTSTANDING BALANCES MUST BE PAID IN FULL PRIOR TO START OF NEW SERVICE, UNLESS PAYMENT ARRANGEMENTS HAVE BEEN MADE. 

    A $25.00 CHARGE WILL BE COLLECTED OR BILLED FOR NO ADVANCE 24-HOUR NOTICE OF RESCHEDULING OR CANCELLING APPOINTMENTS.




. 

(CONTINUE  TO NEXT PAGE)

HOMELAND AVENUE DENTISTRY

PATIENT AUTHORIZATION FORM


 
​I give permission to share the information I have checked with the family, friend or others that I have identified below as being involved in my health care, care coordination or payment of my healthcare. Check all boxes that apply. 

Homeland Avenue Dentistry has my permission to discuss the above information with the following family member, friend or other person.  This information is directly relevant to their involvement in my healthcare (or payment for that care.) 

1. Name:
    Phone Number:
    Relation to Patient:
2. Name:
    Phone Number:
    Relation to Patient:

Names of other entities, including physicians, whom you may release my medical information:

I understand that in certain situations Homeland Avenue Dentistry make speak to other individuals who are involved in my care or payment, if permitted by law, that may not be identified on this form. I understand that I have the right to revoke my permission at any time except where HealthPartners has already made disclosures in reliance upon this request. I understand this permission remains in effect until the time I revoke it in writing. If an updated PERMISSION TO DISCUSS PROTECTED HEALTH INFORMATON WITH FAMILY AND FRIENDS form is received and it has an identical family member/friend/other person listed with updated permissions (different checkboxes), the new version will automatically revoke the previous version on file.  

If other than patient, state relationship & authority to sign: 

(CONTINUE  TO NEXT PAGE)

Permission to Discuss Protected Health Information with Family and Friends - Information Sheet


 
​What are some examples of when this might be useful? 
 

  • If an individual wants to share information with spouse or significant other

  • If an elderly parent wants an adult child to help understand medical treatment instructions

  • If an adult child is helping with billing questions

  • If a friend is helping a patient with health issues 

  • If a college student wants information shared with a parent

  • If an adult child calls to find out his/her parent's appointment time
     

How is the information on the form us?

Anytime your designated person calls or makes a request on your behalf, we will verify the individual has permission to receive the information and then we will share the information.

What if I change my mind?

You can change or revoke (stop) this process at any time.  (if an updated PERMISSION TO DISCUSS PROTECTED HEALTH INFORMATION WIHT FAMILY AND FRIENDS) form is received and it has identical family member/friend/other people listed with updated permissions (different checkboxes), the new version will automatically revoke the previous version on file. 

What happens if I don't complete this form?

We will continue to protect your private health information as required by law.

Does this mean that you will not speak to anyone I haven't specifically named on the form?

No if permitted by law, Homeland Avenue Dentistry may speak to other individudals involved in your care (or payment for that care).. 

If other than patient, state relationship & authority to sign: 

(CONTINUE  TO NEXT PAGE)

PATIENT MEDICATION INFORMATION

Patient Name:

Date of Birth

Please list all current medications and amount taken

Name of Medication

Amount Prescribed

How often taken

bottom of page