Florida Prosthodontics – Medical History

If you are interested in external financing, please check Care Credit or Lending Club.

    Dental Insurance:
    (Please bring a copy of Insurance card to your appointment).

    Please indicate if you have had in the past or present Y (yes) or have not had N (no) to any of the following:

    To the best of my knowledge, all of the preceding answers are true and correct. If I have change in my health or if my medications change, I will inform the doctor at the next appointment without fail.

    CONSENT: The undersigned hereby authorizes Doctor to take x-rays, study models, photographs or any other diagnostic aids deemed appropriate by Doctor to make a thorough diagnosis of the patient's dental needs. I also authorize Doctor to perform any and all forms of treatment, medication and therapy, that may be indicated in connection with and further authorize and consent that Doctor chose and employ such asissance as he/she deems fit. I also understand the use of anesthetic agents embodies a certain risk. I understand that responsibility for payment for Dental Services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless financial arrangements have been made. I further understand that a 1% finance change (18% annually) will be added to any balance over 60 days. In the event of default I (we) promise to pay legal interest on the indebtedness, together with such collection costs and reasonable attorney fees as may be required to effect collection of this note.

    Our practice understands the importance of privacy and is committed to maintaining the confidentiality of your medical/dental information. We make a record of the dental care we provide and may receive similar records from other sources. We use these records to provide or enable other health care providers to provide quality dental care, to obtain payment for services provided to you as allowed by your health plan and to enable us to meet our professional and legal obligations to operate this dental practice properly.
    We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information.