Name (Last, First, Middle): Address: City+State: ZIP: Preferred Name: Social Security Number: Date of Birth: Sex: Marital Status: Ref. Doctor: Ref. Patient: Phone (Home): Phone (Work): Phone (Cell): Your E-mail: Re-Type E-mail: Medical Alerts:   PRIMARY DENTAL INSURANCE COVERAGE Subscriber Name: Relation to Patient: Primary Subscriber Address: Primary Subscriber SS Number: Primary Subscriber Employer: Primary Subscriber Date of Birth: Plain Name: Group Number: Insurance Co. & Address:   SECONDARY DENTAL INSURANCE COVERAGE Secondary Subscriber Name: Relation to Patient: Secondary Subscriber Address: Secondary Subscriber SS Number: Secondary Subscriber Employer: Secondary Subscriber Date of Birth: Plain Name (Secondary): Group Number: Insurance Co. & Address: By checking this box, I confirm being the responsible party.   PATIENT INFORMATION: Sex: Height: Weight:   IF FEMALE, PLEASE ANSWER THE FOLLOWING: Are you taking Birth Control Pills? YesNo Are you pregnant? YesNo If so, number of weeks: Do you smoke or use tobacco? YesNo   CONDITIONS:   Abnormal Bleeding YesNo Alcohol Abuse YesNo Allergies YesNo Anemia YesNo Angina Pectoris YesNo Arthritis YesNo Artificial Bones YesNo Artificial Heart Valve YesNo Asthma YesNo Blood Transfusion YesNo Cancer – Chemotherapy YesNo Colitis YesNo Congenital Heart Defect YesNo Cosmetic Surgery YesNo Diabetes YesNo Difficulty Breathing YesNo Drug Abuse YesNo Emphysema YesNo Epilepsy YesNo Fainting Spells YesNo Fever Blisters YesNo Frequent Headaches YesNo Glaucoma YesNo Hay Fever YesNo Heart Attack YesNo Heart Surgery YesNo Hemophilia YesNo Hepatitis A YesNo Hepatitis B YesNo High Blood Pressure YesNo HIV & AIDS YesNo Kidney Problems YesNo Liver Disease YesNo Low Blood Pressure YesNo Mitral Valve Prolapse YesNo Pace Maker YesNo Pheumocystitis YesNo Psychiatric Problems YesNo Radiation Therapy YesNo Rheumatic Fever YesNo Seizures YesNo Shingles YesNo Sickle Cell Disease YesNo Sinus Problems YesNo Stroke YesNo Thyroid Problems YesNo Tuberculosis YesNo Ulcers YesNo Venereal Disease YesNo Yellow Jaundice YesNo ALLERGIES: Aspirin YesNo Codeine YesNo Dental Anesthetics YesNo Erythromycin YesNo Jewelry YesNo Latex YesNo Metals YesNo Penicillin YesNo Tetracycline YesNo Other Allergies: List any medications you are currently taking: Is there any disease, condition, or problem that you think this office should know about that is not covered above? YesNo If yes, please describe: Notes: Date: Welcome to Wayzata Dental For a smile to last a lifetime. Thank you for giving us the opportunity to serve you. We will always be dedicated to helping smiles last a lifetime, and making dental care COMFORTABLE. Wayzata Dental has been a part of the community since 1948, and has served over three generations of patients. We are also one of the most technologically advanced dental offices in the nation. The value of our state-of-the-art technology to you is comfort and convenience, as well as beauty. You can have the smile you’ve always wanted. Wayzata Dental is a “fee for service” practice. We accept cash, check, VISA, MasterCard, Discover, and American Express. For qualified patients who desire a payment plan we can offer no payment down and no interest for up to six months. If you have insurance, we accept most insurances as an out of network provider. We will be happy to submit the claims for you and collect a portion at the time of service. It is important to note that we do not know and cannot guarantee what your insurance will pay. Ultimately all charges remain your responsibility. When an appointment is made, we set aside time for you. Therefore, if you fail to notify us 24 hours prior, you may be charged $25 for missing an appointment. At Wayzata Dental, your dental health is our top priority. That means we help you learn how advances in today’s dentistry can enhance your smile as you move through all stages of life. Please let us know if you have any questions, and let us know how we are doing! We need your feedback to make sure we are meeting the needs of you and your family. Interest Rate Disclosure: I understand that, as a service to me, Wayzata Dental will assist me in processing any insurance claims. However, I understand I am completely responsible for all fees incurred. Balances not paid in 60 days are subject to 1.5 % interest per month (18% per year). NOTICE OF PRIVACY PRACTICES This notice describes how health information 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 on 4/13/2003 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 Operations: 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 judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment 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 communications 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. You may also request access by sending us a letter to the address at the end of this Notice. We may charge you a reasonable cost-based fee for expenses such as copies, staff time, and postage. 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 your 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 the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the 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 choose to file a complaint with us or with the U.S. Department of Health and Human Services. Contact Officer: Brian Denn 952-473-4900 Fax: 952-473-4672 bdenn@wayzatadental.com Wayzata Dental 250 North Central Avenue Suite 202 Wayzata, MN 55391 © 2002 American Dental Association All Rights Reserved 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 written approval of the American Dental Association. I have read and agree to the Terms and Conditions.