Your Privacy: Information transmitted from this page is encrypted and secure. Your data will never be used by anyone other than your healthcare provider.
DFW User Form
DFW Questionnaire
DFW3

New Patient

New Patient Registration

    • Insurance Information:

  • I have received this practice’s Notice of Privacy Practices written in plain language. The Notice provides in detail the uses and disclosures of my protected health information that may be made by this practice, my individual rights and the practices legal duties with respect to my protected health information. The Notice includes:
  • 1. A statement that this practice is required by law to maintain the privacy of protected health information.
  • 2. A statement that this practice is required to abide by the terms for the notice currently in effect.
  • 3. Types of uses and disclosures that this practice is permitted to make for each of the following purposes: Treatment, Payment, and Health Care Operations.
  • 4. A description of each of the other purposes for which this practice is permitted or required to use or disclose protected health information without my written consent or authorization.
  • 5. A description of other uses and disclosures that are prohibited or materially limited by law.
  • 6. A description of other uses and disclosures that will be made only with my written authorization and that I may revoke such authorization.
  • 7. My individual rights with respect to protected health information and a brief description of how I may exercise these rights in relation to:
  • 1. The right to complain to this practice and to the Secretary of Health and Human Services if I believe my privacy rights has been violated, and that no retaliatory actions will be used against me in the event of such a complaint.
  • 2. The right to request restrictions on certain uses and disclosures of my protected health information, and that this practice is not required to agree to a requested restriction.
  • 3. The right to receive confidential communications of protected health information.
  • 4. The right to inspect and copy protected health information.
  • 5. The right to amend protected health information.
  • 6. The right to receive an accounting of disclosures of protected health information.
  • 7. The right to obtain a paper copy of the Notice of Privacy Practices from this practice upon request.
  • I agree to allow DFW Absolute Dental to release my personal information only for the purpose to remind me of my future appointments. I understand that DFW Absolute Dental prints my appointment time, date and reason on a reminder post card that is sent to my home or address, I have provided, one to two weeks prior to my appointment time.
  • This practice reserves the right to change the terms of its Notice of Privacy Practices and to make new provisions effective for all protected health information that it maintains. I understand that I can obtain this practice’s current Notice of Privacy Practices upon request.
 

Intake Form

Health History

  • Although dental personnel primarily treat the area in and around your mouth, your mouth is apart of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. Thank you for answering the following questions.

    • Women: Are you

 

Dental Treatment Consent Form

Treatment Consent

  • I agree to disclose all previous illness and medical history. Undisclosed medical information and current medications, allergies or illness are risk factors.
  • I understand that antibiotics and other medicines can cause allergic reactions and even life-threatening anaphylaxis. Also, some antibiotics interfere with birth-control pills. Latex allergy can cause rashes and itching. Epinephrine increases heartbeat and depending on my health, may be dangerous to me.
  • If someone is inadvertently stuck with a needle used on me, I consent to have blood drawn for analysis.
  • Some teeth may need a root canal even after a simple filling. Fillings and crowns do take away tooth structure and a percentage of these teeth end up needing a root canal after the filling or crown is done. Warranty is only valid if routine 6 month appointments are maintained.
  • Root canals can fail and may require additional treatment or I may end up having the tooth extracted.
  • Porcelain crowns, veneers, cosmetic bonding and composite fillings are esthetically pleasing. However, I understand that if they chip or break after in use successfully, I am responsible for repairs or remakes. Once a crown, veneer, bonding, or filling is placed, I understand the color cannot be changed.
  • I understand that I may need treatment beyond what was originally planned. If a crowned tooth becomes painful and will need a root canal, or I may be referred to a specialist for additional care (root canal was not successful). I agree to be financially responsible for the additional or specialty care.
  • If I don’t floss or if I smoke, I can expect to have deteriorating gum condition. I agree that if I need gum treatment, I will not insist that I simply get a cleaning (prophylaxis).
  • I understand that all extractions or surgeries carry risks. Some are minor, like a dry socket following an extraction. Some are life threatening, such as post-surgical infections or anaphylaxis.
  • There are charges beyond what insurance will pay, such as bleaching or cosmetic work. As a service to our patients, this office will file insurance claims on their behalf as a courtesy. I understand that what may be quoted as my portion (co-payment) is only an estimate. I agree to be financially responsible for what insurance does not cover and that the office only allows 90 days for the insurance to pay. The balance is ALWAYS my responsibility.
  • I agree to give a 24 hour notice for cancellation or pay the broken appointment fee of $50.00. I understand that leaving a message after the office is closed the day (or weekend) before is NOT sufficient notice.
 
Extended Validation SSL Certificate