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THIS SECTION HAS EXAMPLES AND TIPS FOR SOME COMMON DENTAL OFFICE FORMS.
YOUR OFFICE MAY HAVE FORMS THAT LOOK DIFFERENT TO OURS, OR MAY HAVE SOME FORMS THAT WE DON'T SHOW HERE.
IF ANYTHING IS CONFUSING YOU, FEEL FREE TO LET THE DENTAL OFFICE STAFF KNOW. THEY'RE THERE TO HELP YOU!
WE HAVE EXAMPLES OF THESE COMMON FORMS:
PATIENT REGISTRATION FORM
sometimes called 'patient information' + sometimes combined with the medical history form
MEDICAL HISTORY FORM
sometimes this is combined with other forms. use this example to check out common questions ahead of time!
HIPAA (OR PRIVACY) FORM
Health Insurance Portability and Accountability Act (HIPAA) helps protect your privacy and keep your healthcare information safe
CONSENT TO TREAT A MINOR FORM
under 18? your parent or guardian can give consent for you to get care and treatment at the dentist
CHECK THEM OUT BELOW!
patient registration form
EXAMPLE FORM
your dentist office's form may look different, but it will probably have a lot of the same questions on it. every dental office will have this form
Patient registration-revised.pdfRUN THROUGH IT:
here's how to fill it out. if there's anything new or different on your dentist's form, always feel free to ask the office staff for an explanation!
medical history form
EXAMPLE FORM
your dentist office's form may look different, but it will probably have a lot of the same questions on it. every dental office will have this form
YMM medical hx- L (002).pdfRUN THROUGH IT:
here's how to fill it out. if there's anything new or different on your dentist's form, always feel free to ask the office staff for an explanation!
HIPAA (or privacy) form
EXAMPLE FORM
your dentist office's form may look different + it might be called a 'privacy' or 'health information' form
the purpose of the form is to let you know your rights as a patient and to tell you how your dental office will protect your health information
our form has some info on what HIPAA means, and what the Accountability Act does for you. the CDC has more great info on the HIPAA here. every dental office should have this form!
YMM letterhead HIPAA.pdfconsent to treat a minor form
EXAMPLE FORM
if you are under 18 and you plan to go to the dental office by yourself, your parent or guardian will need to give consent for you to receive care
Consent to treat a minor form (1).pdfIF YOU DON'T HAVE SOMEONE WHO CAN SIGN FOR YOU
OR ANYONE WHO WILL SIGN FOR YOU
the state of Alaska has a statute (AS § 25.20.025) that allows a minor who is living apart from their parents or legal guardian, and managing their own financial affairs, to give consent for medical and dental services (with some exceptions)
when the parent or legal guardian of the minor cannot be contacted or, if contacted, is unwilling either to grant or withhold consent, the dental office can counsel the minor and inform them so that they can consent to care
and finally, a secret fifth thing
payment/policy form
lots of offices have a form for patients to sign that shares their office payment policy/policies. this is usually to make sure that you, the patient, or the member of the insurance you are using (if that's not you), have agreed to pay any costs for your care that aren't paid by insurance
we don't have an example form here, because these forms are really unique to each office!
but be prepared to see this form when you check in for your first appointment at a dental office
SOME EXCEPTIONS: if you know you don't have insurance, or a way to pay for expensive care, you may get care at a low cost or free clinic (like those on our 'find a dentist' page)
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