CONFIDENTIAL INFORMATION QUESTIONNAIRE

  • EMERGENCY CONTACT INFORMATION

    PERSON WE MAY CONTACT IN CASE OF AN EMERGENCY (OTHER THAN YOUR FAMILY HOME)
  • REQUEST FOR CONFIDENTIAL COMMUNICATION

    AS MY DENTAL CARE PROVIDER, YOU MAY DO THE FOLLOWING WITH MY PERMISSION:
  • INSURANCE AND FINANCIAL INFORMATION INSURANCE COVERAGE

  • RELEASE INFORMATION

    YOU MAY DISCUSS MY HEALTHCARE WITH
  • CONFIRMATIONS

  • ASSIGNMENT & RELEASE

    I hereby authorize (1) any available insurance benefits to be paid directly to my dentist, (2) the release of my dental health care information for any of my dental health care insurance claim, (3) the use of my dental records by my dentist in any professional manner that he/she determines, (4) the making of videotapes, photographs, and x-rays of my dental care treatment (collectively "My Images"), and (5) my dentist's use of My Images in scientific papers, demonstrations and/or presentations without compensation to me. I agree that to the extent of the cost of the dental care provided by my dentist is not covered by insurance, I am obligated to pay him/her such uninsured cost (the "Uninsured Costs") in accordance with his/her payment terms and policies. Finally, I certify that I have read or had read to me the contents of this form and understand the risks and limitations involved with the dental treatment that I am to receive.
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  • If the above named Patient is a minor or unable to pay the his/her Uninsured Costs, the undersigned agrees to guaranty the payment of such Uninsured Costs to the Patient’s dentist in accordance with his/her payment terms and policies.
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