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Welcome to Our Practice

We would like to take this opportunity to thank you for choosing our office to provide your children’s dental care. We hope you always feel welcomed and comfortable when you come to see us. We are committed to giving you the best service possible and want you to be happy here in your dental home. Below are some items that will help us to achieve our common goal of high quality dental care in a gentle and enthusiastic environment.

We will do our best to give you a “guestimate” of your investment in your children’s dental health for each upcoming visit, based on your treatment needs. You will be responsible for your portion at each visit and as a courtesy to you we will accept assignment of benefits on your behalf from your dental insurance company. Should any payments go directly to you from your insurance company for services you received in our dental office they should be forwarded to us immediately so that we can credit your account accordingly.

We realize that you have many demands on your time. We are committed to respecting your time and will attempt to make your visits as convenient as possible. In return, we ask that our patients respect our time. In the event you need to change your appointment we request a 48-hour advance notice. We thank you in advance for your prompt attention to this request.

We are happy to receive payments in the form of cash, check or credit card (MasterCard, Visa, American Express and Discover). We also offer no interest or low interest monthly payments through Care Credit. (See us for details or visit their website at www.Carecredit.com). In the event that you inadvertently write a check to our office without sufficient funds in your account, a returned check fee of $35.00 will be added to your account.

Thank you again for trusting us with all your family’s dental needs. We look forward to serving you and your family.

I understand and accept the financial and appointment policies listed above and have had any and all questions answered to my satisfaction. I hereby authorize my insurance benefits to be paid directly to Beautiful Smiles. This request will remain in effect until revoked by me in writing. A photocopy of this assignment is to be considered as valid as the original.

Parent (or legal guardian)

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Date:-------------

Patient Information

Patient Name

Nickname (if any)

Patient Home Address

City / State / Zip

Phone Number / Cell Number

Patient Age / Date of Birth

Patient SSN / Sex

Male Female

Patient Grade Level and School

Parent/Guardian's Name (1)

Parent/Guardian's Name (2)

Siblings: Number of Brothers

Number of Sisters

Are Siblings existing patients?

Yes No

Patient's Primary Care Doctor

Patient Health History

(Questions asked so hereditary and environmental factors can be evaluated)

Birth History

Was this child premature?

Yes No

If premature, how many weeks?

Please note any prescription medicine taking during pregnancy

Were there any problems during pregnancy?

Yes No

Were there any problems with the delivery?

Yes No

Is this child adopted?

Yes No

General Health

Is a physician currently treating your child for a specific problem

Yes No

If so, for what reason

Is your child taking medication at this time

Yes No

Drug

Dose

Frequency

Reason

Please note any past prescription medications

Has your child shown any allergies or unusual reactions to medications (e.g. penicillin and amoxicillin) or substances such as latex or nickel

Are your child's immunizations up to date?.

Yes No

Does your child receive a yearly flu shot?

Yes No

I authorize and grant permission for my child to receive dental treatment. I understand that any and all treatments will be discussed prior to them being performed.

Signed:

Click to Sign

Date:-------------

Relationship to child:

I have reviewed (see below) the copy of the Beautiful Smiles Children’s Dental Health Notice of Privacy Practices.

Signed:

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Date:-------------

Privacy Practices

Beautiful Smiles: Children's Dental Health
NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMAITON ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect 1/1/2003, and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operation: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgement disclosing only health information that is directly relevant to the person's involvement in your healthcare. We will also use our professional judgement and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communication without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS
Access: You Have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $.35 for each page. $18.00 per hour for staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request and alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

QUESTIONS AND COMPLAINTS

If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated y our privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to us U.S. Department of Health and Human services. We will provide you with the address to file your complaint with U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you chose to file a complaint with us or with the U.S. Department of Health and Human Services.

Contact Office: Drew J. Carlin, DMD

Telephone: (814) 455-2158 Fax: (814) 480-8127

Address: 5125 Zuck road, Erie, PA 16506

©2002 American Dental Association
All Rights Reseverd

Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior writen approval of the American Dental Association.

This Form is educational only, does not constitute legal advice, and covers only federal, not state, law (August 14, 2002).

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Welcome to Our Practice

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Patient Health History

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General Health

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Dental Health History

Please check the reason(s) for this visit:

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NOTICE OF PRIVACY PRACTICES

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Main Header

Welcome to Our Practice

Click to Sign

Patient Information

Patient Information

Patient Health History

Patient Health History

Birth History

General Health

Please indicate if your child has a history of any of the following diseases or conditions:

Dental Health History

Please check the reason(s) for this visit:

Click to Sign

Click to Sign

Privacy Practices

Privacy Practices

NOTICE OF PRIVACY PRACTICES

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