Hillview Family Dentistry
119 Topfield Rd
Louisville, KY 40229
Call us to make an appointment:
(502) 957-4408
New Patient Documents (please right click on mouse and print):
Hillview Family Dentistry
Today’s Date: ____________________
Patient’s Name:______________________________________________________ D.O.B. _________________
Home Address: ______________________________________________________________________________
City: _______________________________ State: _______________________ Zip: ______________________
Employer: ___________________________ Work Number: ______________________________________
E – Mail address: _____________________________________________________________________________
Home Phone Number: ___________________________ Cell Number: ___________________________
Social Security Number: _____________________________
Person Responsible for account: ___________________________________________________________
Driver License Number: _____________________________
How did you hear of our office? ____________________________________________________________
Dental Insurance: Y N Insured Name: _________________________________________________
Insured’s Social Number: ______________________ D.O.B. ___________________________________
Insurance Company: ________________________________________________________________________
Insurance Company Address: ______________________________________________________________
Insured Employer: _____________________________ Phone Number: _________________________
ID Number: _______________________________ Group Number: ______________________________
Secondary Insurance: Y N Insured Name: _____________________________________________
Insured’s Social Number _________________________ D.O.B. _________________________________
Insurance Company: ______________________________________________________________________
Insurance Company Address: ____________________________________________________________
Insured Employer: _____________________________ Phone Number: _______________________
ID Number: _______________________________ Group Number: _____________________________
Hillview Family Dentistry
Consent to the Use and Disclosure of Health Information for Treatment, Payment, or Healthcare Operations. (HIPPA)
I understand that as part of my healthcare, this organization originates and maintains health records describing my health history, symptoms, examination and test results, diagnoses, treatment, and any plans for future care or treatment. I understand that this information serves as:
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a basis for planning my care and treatment
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a means of communication among the many health professionals who contribute to my care.
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a source of information for applying my diagnosis and surgical information to my bill
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a means by which a third-party payer can verify that services billed were actually provided.
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and a tool for routine healthcare operations such as assessing quality and reviewing the competence of healthcare professionals
I understand and have been provided with a Notice of Information Practices that provides a more complete description of information uses and disclosures. I understand that I have the right to review the notice prior to signing this consent. I understand that the organization reserves the right to change their notice and practices and prior to implementation will mail a copy of any revised notice to the address I’ve provided. I understand that I have the right to object to the use of my health information for directory purposes. I understand that I have the right to request restrictions as to how my health information may be used or disclosed to carry out treatment, payment, or healthcare operations and that the organization is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already take action in reliance thereon.
I request the following restrictions to the use or disclosure of my health information.
Accepted _________________ Denied __________________
Signature of Patient or Legal Representative: _________________________________________
Today’s Date: ____________________________
Hillview Family Dentistry
119 Topfield Rd Louisville, KY 40229
Office Policy
Thank you for choosing us as your dental health provider. We are committed to your successful treatment. Please understand that payment of your bill is considered a part of your treatment. In order to keep our fees from rising dramatically and to minimized the expenses of billing and bookkeeping, the following financial policy will be in effect at our office:
All patients must complete our patient information form and insurance form before seeing the doctor.
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Estimated portion of payment is due at the time of service.
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We accept cash, checks, debit cards, Visa, Master Card, and Discover
Dental insurance does not cover 100% of the cost of your treatment. Because of this and the extreme delay in receiving payment from many insurance companies, you will be asked to pay your deductible and your Estimated portion on the day services are rendered. We will Estimate as closely as possible your coverage, but until we actually receive the insurance payment, it is only an Estimate. We will assist you in dealing with your insurance company, but ultimate responsibility lies with you. Your insurance is a contract between you and the insurance company. After 90 days your account balance is due in full even if you’re insurance has not yet paid. If the account is not paid within the 120 days of the date of service and no financial arrangements have been made, you will be responsible for legal fees, collection agency fees, interest charges and other expenses incurred in the collection of your account.
Late Payment Charges: If you minimum payment is not received by the due date, you may be assessed a late payment charge. The amount of the late payment charge to be assessed is the maximum amount authorized under the laws of the state of your domicile. IN most states, the late charge will be $5.00 or 5% of the past due minimum payment, which ever is great, with maximum of $20.00.
Finance Charge: A finances charge is imposed on those charges not paid in full within 90 days of the date you were first billed for the charges. The finance charge is periodic rate of .66% per month with an annual rate of 8%. The finance charge is computed by multiplying the balance on which the finance charge is computed by the periodic rate shown above. There is a $1.00 minimum finance charge.
If you think that you have been incorrectly, or if you need more information about a transaction on your bill, please call the office and we will be happy to assist your. Every effort will be made to make suitable arrangements for payment but if the account fails to be paid and there are no arrangements made, after 120 days the account may be turned over to our attorneys and all collections fees will be billed to you the patient.
Initial ______
Office Policies cont.
In order to provide you with the best care possible, there are some guidelines we follow to keep the office running smoothly.
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Office visits are by appointment only, if you have and emergency, please call and we will work you in as soon as possible. Patients with appointments hold priority unless the emergency is serious. Therefore, there may be a wit if you are worked in. We appreciate your understanding and cooperation on this matter.
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If you can not make your scheduled appointment, it is necessary to inform the office 24-hours in advance. We will be more than happy to reschedule your appointment at to a more convenient time for you. On your first missed appointment occurrence you will receive a warning letter. On you second missed appointment you will receive a $25.00 failed appointment charge to your account. After the third missed appointment, without 24-hour notice, the doctor reserves the right to dismiss you as a patient.
We strongly urge you to keep scheduled appointments especially if you are in the middle of treatment. We are usually booked 3-4 weeks in advance so any rescheduling will result in a delay in finishing you case. We do understand that emergencies happen and we will take that into consideration.
Authorization and Release
I authorize the dentist to release any information including the diagnosis and the records of any treatment of examination rendered during the period of such dental care to third party payers and health practitioner. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand that my dental insurance carrier may pay less than the actual bill for service. I agree to be responsible for the payment of all services rendered on my behalf of my dependents.
__________________________________ __________________
Signature Date
Hillview Family Dentistry
119 Topfield Rd. Louisville, KY 40229
502-957-4408
Dental Consent Form
I hereby authorize and direct the dentist of Hillview Family Dentistry to perform the following dental treatment or oral surgery procedures, including the use of any necessary or advisable local anesthesia, radiographs or diagnostic aids:
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Consult with examination for future treatment.
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Preventive hygiene treatment, (Prophylaxis) and the application of tropical fluoride.
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Application of plastic “sealants” to the grooves of the teeth
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Treatment of diseased or injured teeth with restorations(fillings and crowns).
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Replacement of missing teeth with dental prostheses (bridges, partials and dentures)
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Removal (extraction) of one or more teeth.
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Treatment of diseased or injured oral tissue (hard and/or soft)
I understand there are risks involved in this treatment and hereby acknowledge that these risks will be explained to me. I will have the opportunity to ask questions regarding the treatment and the risks and that I dully understand the same.
I will be advised that the success of the dental treatment to be provided will require the patient or parents of the patient to follow post-care instructions. I agree that the success of the treatment requires that all post-operative and post – care instructions be followed and regular office visits as scheduled must be maintained.
I realized that during the course of treatment unforeseen circumstances may necessitate additional or different procedures from those discussed. I therefore authorize and request the performances of any additional procedures that are deemed necessary for desirable oral health and well being, in the judgment of the treating dentist.
There are possible risks and complications associated with the administration of local anesthesia, sedation and drugs. The most common of these are swelling, bleeding, pain, nausea, vomiting, bruising, tingling, numbness of the lips, gums, face and tongue, allergic reactions, hematoma, (swelling or bleeding at the injection site), fainting, lip or cheek biting resulting in ulceration and infection of the mucosa. I also understand that there are rare potential risks such as unfavorable reactions to medications in the respiratory and cardiovascular collapse (stopping of breathing or heart function) and lack of oxygen to the brain that could result in coma or death. I understand and have been informed o the above risk and complications.
I agree to the use of local anesthesia and the use of nitrous oxide/oxygen analgesia depending on the judgment of the dentist. Nitrous oxide/oxygen may produce nausea and vomiting. I am also aware that the nosepiece leaves an indentation or ring around the nose, which disappears shortly afterwards. I understand and have been informed of the above risks and complications.
I hereby state that I have read and understand this consent and that all questions about the procedures will be answered in a satisfactory manner and that I have the right to be provided answers to questions which may arise during and after the course of my treatment.
I also understand that this consent will remain in effect until such time that I choose to terminate it.
Patient’s Name _________________________________________________________________________
Name of Parent or Guardian_______________________________________________________________
Signature of Patient or Parent/Guardian______________________________________________________
Hillview Family Dentistry
119 Topfield Rd
Louisville, KY 40229
502-957-4408
Dental History
Any sensitivity? (Y/N) ________ (Hot, Cold, Sweet)
Where? UL, UR, LL, LR
Headaches, earaches, neck pain, jaw joint pain? (Y/N) ________
Teeth or fillings breaking? (Y/N) __________
Grinding or clenching teeth? (Y/N) _______
Bleeding, swollen or irritated gums? (Y/N) _________
Loose, Tipped or shifting teeth? (Y/N) ________
Bad Breath? (Y/N) ________
Do you have, or have you had any of the following? (Y/N) ________
Denture, Partial dentures, Braces, Periodontal (gum) disease?
Your last cleaning? ________________________________
Your last oral cancer screening? ______________________
Do you smoke or use chewing tobacco? (Y/N) ________
How much? ___________ How Long? __________
If I could change my smile, I would: (circle)
Make them whiter
Make them straighter
Close Spaces
Replace black metal fillings with tooth colored restorations
Replace old crowns that don’t match
Your previous Dentist? __________________________
City:____________________ State: ______________________
On a scale of 1-10 10 being the highest rating:
How important is your dental health to you? __________________
Where would you rate your current dental health? _____________
Where do you want your dental health to be? _________________
Why did you leave your previous dentist? _______________________________
_________________________________________________________________
What is the most important thing to you about your future smile and dental health?
___________________________________________________________________
What is the most important thing to you about you dental visit today?
____________________________________________________________________
Hillview Family Dentistry
119 Topfield Rd.
Louisville, KY 40229
502-957-4408
Health History
What medications are you currently taking? ______________________________________________________________________________________
______________________________________________________________________________________
If female are you taking birth control pills? (Y/N) ________
Are you pregnant? (Y/N) ________
Are you nursing? (Y/N) ________
Please circle any conditions that pertain to your health.
Any questions please ask front desk or dentist.
Abnormal Bleeding
Allergies
Heart Attack
Angina Pectoris
Hepatitis A
Hepatitis B
HIV + AIDS
Liver Disease
Diabetes
Pneumocystitis
Emphysema
Fainting Spells
Frequent Headaches
Glaucoma
Hay Fever
Tuberculosis
Hemophilia
Yellow Jaundice
Asthma
Cancer/Chemo
Cosmetic Surgery
Mitral Valve Prolapse
Psychiatric Problems
Rheumatic Fever
Shingles
Sinus Problems
Alcohol abuse
Thyroid Problems
Heart Surgery
Venereal Disease
Artificial Bones
High Blood Pressure
Kidney Problems
Low Blood Pressure
Difficulty Breathing
Drug Abuse
Epilepsy
Fever Blisters
Stroke
Anemia
Ulcers
Arthritis
Artificial Heart Valve
Blood Transfusion
Colitis
Congenital Heart Defect
Pace Maker
Radiation Therapy
Seizures
Sickle Cell Disease
Explain any other condition if not listed: ____________________________________________
______________________________________________________________________________
Allergies: Aspirin Codeine Erythromycin Jewelry Latex Metals Penicillin Tetracycline:
Others: ______________________________________________