Today's Date First Name Middle Name Last Name I prefer to be called Male Female Address Unit# City State Zip Date of birth Age Social Security # Driver's License # Mobile # Work # Home # Primary contact number #(please check one) Home Work Cell OK to Text Yes No Best time to call E-mail OK to Email Yes No Employer Occupation Spouse's name Occupation Who may we thank for referring you? Reason for today's visit Are you currently in pain? Yes No Describe: Do you have any dental Concerns now? Yes No Describe: Have you ever had trouble with a previous dental treatment? Yes No Describe: Level of anxiety about seeing the dentist: (least) 1 2 3 4 5 (most) Date of last dental exam Date of last cleaning Date of last full mouth X-rays Previous dentist's name Reason for choosing this office Anything else that you want our office to know about you that will help us to serve you better?   Medical History Do you require antibiotics before dental treatment? Yes No Reason Have you been hospitalized or under the care of a medical doctor during the past 2 years? Yes No If yes, for what Hospital or Physician's name Phone # Physician's City State List ALL medications including Prescription, Over-the-Counter, Herbal Supplements, Vitamins, Minerals, Homeopathic Do you use tobacco? Yes No If so what type: Smoke Dip/chew E-cig/Vape CBD Others: Do you drink alcohol? Yes No Do you use a controlled substance? Yes No Bisphosphonate/Bone replacement therapy? Yes No Taken via: Pill Injection IV Yes No Heart (Surgery, Disease, Attack) Stroke Heart Murmur Heart Pacemaker Mitral Valve Prolapse (MVP) Artificial Heart Valve Rheumatic/Scarlet Fever High blood pressure Low blood pressure Atrial Fibrillation Diabetes Yes No HbA1c score Date Joint Replacement Surgery Yes No When Joint GERD/acid reflux Yes No Cancer type Yes No Yes No Radiation/Chemotherapy Cold Sores/Herpes/Fever Blisters. Tuberculosis (TB) Hepatitis A,B, or C AIDS/HIV/ARC Venereal Disease/STD/HPV Yes No Asthma Sinusitis/Hay Fever Allergies or Hives Emphysema/COPD Yes No Alzheimer's or Dementia Epilepsy or Seizures Nervousness/Anxiety/Depression Thyroid Problems Autoimmune Disease: Lupus Celiac MS Crohn's Rheumatoid Arthritis Sjogren's Other: Yes No Do you occasionally snore? Have you stopped breathing or gasped for air while sleeping? Are you often sleepy during the day? Have you had a sleep study? If so, when? Have you been diagnosed with Sleep Apnea? Yes No Are you currently using or have used: CPAP T.A.P Other device Yes No Hearing disorder Alcohol/drug abuse Glaucoma Arthritis Anemia Blood disease Bruise Easily Any other condition Not listed above: ALLERGIES Any allergy or adverse reaction to any of the following Latex Anesthetics ("caine") Codeine Penicillin Sulfa Drugs Sedatives Erythromycin Aspirin Jewelry/Metals Tetracycline Iodine and Shellfish None (No known diagnosed allergies) Other Antibiotics Other  Women Only: Are you pregnant or think you may be pregnant? Yes No If Yes, what is your due date? Are you taking birth control pills? Yes No Are you taking Hormone Replacement Therapy? Yes No   Patient signature Date: I have verbally reviewed the Medical/Dental information above with the patient here in: Doctor Signature ________________________________ Date ________________ Dental History How would you rate your overall dental health? Great Good Fair Poor Have you ever had: Yes No Periodontal disease/gum treatment Orthodontic treatment Oral surgery Dental implants Yes No Discomfort/pain in your jaw joint (TMJ/TMD) Your teeth ground or bite adjusted Serious injury to the mouth or face Gum grafting If Yes to any of the above questions, please describe Is there anything else about your past dental treatment that you would like us to know Have you ever had any complications from a dental procedure? Yes No If so, please explain Do you have any missing teeth that have not been replaced? Yes No Why not? Do you wear any removable dental appliances? Yes No What type and for how long? Have you ever had your teeth whitened or bleached? Yes No Would you like to? How do you feel about the appearance of your smile and what would you change if you could? Do you have or had any of the following signs or symptoms: Dry mouth Day Night Yes No Tooth fractures, broken fillings Yes No Mouth breather Day Night Yes No Loose or separating teeth Yes No Red, swollen, or tender gums Yes No Sores, ulcers, blisters, rough spots Yes No Avoid any areas when brushing/chewing Yes No Food catches between your teeth Yes No Gums bleed when Floss Brush Yes No Unpleasant taste or bad breath Yes No Changes in the way your teeth fit together Yes No Frequent morning headaches Yes No Clench or grind your teeth Yes No Teeth sensitive to Hot Cold Pressure Yes No Do you have a Night Guard? Yes No When do you use it Nightly As needed Occasionally Home Care How many times a day do you brush your teeth? How often do you clean between your teeth? What do you use? IF you use an Electric toothbrush Battery Rechargeable Brand IF you use a Manual toothbrush: Bristles Type: Firm Medium Soft Which type and brand of toothpaste do you prefer (if any)? Mouthwash/Mouth rinse Yes No If yes, what brand How often Do you like to use any other dental aids? Yes No Waterpik Airfloss Interdental Brushes Floss Picks Soft Picks Reach Flosser Toothpicks Other Any other homeopathic dental products Yes No If yes, what are their name(s)? Do you have any concerns for your dental hygienist Dental Insurance Primary Carrier Insurance co. name Insurance co. phone Address (Street, City, State, ZIP) Group no. (Plan or Policy no.) Insured's I.D. no. Insured's name Relationship to patient Date of birth Insured's social security no Insured's employer name Is insured a patient in our practice? Yes No Secondary Carrier Insurance co. name Insurance co. phone Address (Street, City, State, ZIP) Group no. (Plan or Policy no.) Insured's I.D. no. Insured's name Relationship to patient Date of birth Insured's social security no Insured's employer name Is insured a patient in our practice? Yes No Person Financially Responsible for Account Name Relationship to patient Social security no. Phone Driver's license no. Date of birth Address (Street, City, State, ZIP) Employer Work phone Preferred payment method: Cash Credit Card Visa/MC/AMEX no. Exp. Date If patient is a minor, name of parent or legal guardian and relationship Is this parent or legal guardian currently a patient in our office? Yes No With whom may we discuss your treatment other than your insurance company and Medical/Dental professionals? ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES *You May Refuse to Sign This Acknowledgement* I, , have received a copy of this office's Notice of Privacy Practices Please Print Name Patient signature Date: Person to contact in case of emergency Name Relationship City State Cell Phone Home phone Work Phone OFFICE USE ONLY I VERBALLY REVIEWED THE MEDICAL / DENTAL INFORMATION ABOVE WITH THE PATIENT NAMED HEREIN Date www.NorthParkDental.com NOTICE OF PRIVACY PRACTICES Northpark Dental Associates 6500 Greenville Ave. Suite 303, Dallas, TX 75206 (214) 696-8096 Fax: (214) 696-8095 Info@NorthParkDental.com THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. We respect our legal obligation to keep health information that identifies you private We are obligated by law to give you notice of our privacy practices. This Notice describes how we protect your health information and what rights you have regarding it. TREATMENT, PAYMENT, AND HEALTH CARE OPERATIONS The most common reason why we use or disclose your health information is for treatment, payment or health care operations. Examples of how we use or disclose information for treatment purposes are: setting up an appointment for you; examining your teeth; prescribing medications and faxing them to be filled; referring you to another doctor or clinic for other health care or services; or getting copies of your health information from another professional that you may have seen before us. Examples of how we use or disclose your health information for payment purposes are: asking you about your health or dental care plans, or other sources of payment; preparing and sending bills or claims; and collecting unpaid amounts (either ourselves or through a collection agency or attorney). "Health care operations" mean those administrative and managerial functions that we have to do in order to run our office. Examples of how we use or disclose your health information for health care operations are: financial or billing audits; internal quality assurance; personnel decisions; participation in managed care plans; defense of legal matters; business planning and outside storage of our records. We routinely use your health information inside our office for these purposes without any special permission. If we need to disclose your health information outside of our office for these reasons, we will not ask you for special written permission. USES AND DISCLOSURES FOR OTHER REASONS WITHOUT PERMISSION In some limited situations, the law allows or requires us to use or disclose your health information without your permission. Not all of these situations will apply to us; some may never come up at our office at all. Such uses or disclosures are: ● when a state or federal law mandates that certain health information be reported for a specific purpose; ● for public health purposes, such as contagious disease reporting, investigation or surveillance; and notices to and from the federal Food and Drug Administration regarding drugs or medical devices; ● disclosures to governmental authorities about victims of suspected abuse, neglect or domestic violence; ● uses and disclosures for health oversight activities, such as for the licensing of doctors; for audits by Medicare or Medicaid; or for investigation of possible violations of health care laws; ● disclosures for judicial and administrative proceedings, such as in response to subpoenas or orders of courts or administrative agencies; ● disclosures for law enforcement purposes, such as to provide information about someone who is or is suspected to be a victim of a crime; to provide information about a crime at our office; or to report a crime that happened somewhere else; disclosure to a medical examiner to identify a dead person or to determine the cause of death; or to funeral directors to aid in burial; or to organizations that handle organ or tissue donations; ● uses or disclosures for health related research: ● uses and disclosures to prevent a serious threat to health or safety; ● uses or disclosures for specialized government functions, such as for the protection of the president or high ranking government officials; for lawful national intelligence activities; for military purposes; or for the evaluation and health of members of the foreign service, ● disclosures of de-identified information; ● disclosures relating to worker's compensation programs; ● disclosures of a "limited data set" for research, public health, or health care operations; ● incidental disclosures that are an unavoidable by-product of permitted uses or disclosures; ● disclosures or "business associates" who perform health care operations for us and who commit to respect the privacy of your health information Unless you object, we will also share relevant information about your care with your family or friends who are helping you with your dental care. APPOINTMENT REMINDERS We may (call, write or text) to remind you of scheduled appointments, or that it is time to make a routine appointment. We may also (call, write or text) to notify you of other treatments or services available at our office that might help you. Unless you tell us otherwise, we will mail you an appointment reminder on a post card, and/or leave you a reminder message on your home answering machine or with someone who answers your phone if you are not home. OTHER USES AND DISCLOSURES We will not make any other uses or disclosures of your health information unless you sign a written "authorization form." The content of an "authorization form" is determined by federal law. Sometimes, we may initiate the authorization process if the use or disclosure is our idea. Sometimes, you may initiate the process if it's your idea for us to send your information to someone else. Typically, in this situation you will give us a properly completed authorization form, or you can use one of ours. If we initiate the process and ask you to sign an authorization form, you do not have to sign it. If you do not sign the authorization, we cannot make the use or disclosure. If you do sign one, you may revoke it at any time unless we have already acted in reliance upon it. Revocations must be in writing. Send them to the office contact person named at the beginning of this Notice. YOUR RIGHTS REGARDING YOUR HEALTH INFORMATION The law gives you many rights regarding your health information. You can: ● ask us to restrict our uses and disclosures for purposes of treatment (except emergency treatment), payment or health care operations. We do not have to agree to do this, but if we agree, we must honor the restrictions that you want. To ask for a restriction, send a written request to the office contact person at the address, fax or E Mail shown at the beginning of this Notice. ● ask us to communicate with you in a confidential way, such as by phoning you at work rather than at home, by mailing health information on to a different address, or by using E mail to your personal E Mail address. We will accommodate these requests if they are reasonable, and if you pay us for any extra cost. If you want to ask for confidential communications, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice. ● ask to see or to get photocopies of your health information. By law, there are a few limited situations in which we can refuse to permit access or copying. For the most part, however, you will be able to review or have a copy of your health information within 30 days of asking us (or sixty days if the information is stored off-site. You may have to pay for photocopies in advance. If we deny your request, we will send you a written explanation, and instructions about how to get an impartial review of our denial if one is legally available. By law, we can have one 30 day extension of the time for us to give you access or photocopies if we send you a written notice of the extension. If you want to review or get photocopies of your health information, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice. ● ask us to amend your health information if you think that it is incorrect or incomplete. If we agree, we will amend the information within 60 days from when you ask us. We will send the corrected information to persons who we know got the wrong information, and others that you specify. If we do not agree, you can write a statement of your position, and we will include it with your health information along with any rebuttal statement that we may write. Once your statement of position and/or our rebuttal is included in your health information, we will send it along whenever we make a permitted disclosure of your health information. By law, we can have one 30 day extension of time to consider a request for amendment if we notify you in writing of the extension. If you want to ask us to amend your health information, send a written request, including your reasons for the amendment, to the office contact person at the address, fax or E mail shown at the beginning of this Notice, ● get a list of the disclosures that we have made of your health information within the past six years (or a shorter period if you want). By law, the list will not include. disclosures for purposes of treatment, payment or health care operations; disclosures with your authorization; incidental disclosures; disclosures required by law; and some other limited disclosures. You are entitled to one such list per year without charge. If you want more frequent lists, you will have to pay for them in advance. We will usually respond to your request within 60 days of receiving it, but by law we can have one 30 day extension of time if we notify you of the extension in writing. If you want a list, send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice. ● get additional paper copies of this Notice of Privacy Practices upon request. It does not matter whether you got one electronically or in paper form already. If you want additional paper copies. send a written request to the office contact person at the address, fax or E mail shown at the beginning of this Notice OUR NOTICE OF PRIVACY PRACTICES By law, we must abide by the terms of this Notice of Privacy Practices until we choose to change it. We reserve the right to change this notice at any time as allowed by law. If we change this Notice, the new privacy practices will apply to your health information that we already have as well as to such information that we may generate in the future. If we change our Notice of Privacy Practices, we will post the new notice in our office, have copies available in our office, and post it on our Website. COMPLAINTS If you think that we have not properly respected the privacy of your health information, you are free to complain to us or the U.S. Department of Health and Human Services, Office for Civil Rights. We will not retaliate against you if you make a complaint. If you want to complain to us, send a written complaint to the office contact person at the address, fax or E mail shown at the beginning of this Notice. If you prefer, you can discuss your complaint in person or by phone. FOR MORE INFORMATION If you want more information about our privacy practices, call or visit the office contact person at the address or phone number shown at the beginning of this Notice. ACKNOWLEDGEMENT OF RECEIPT I acknowledge that I received a copy of Northpark Dental Associates Notice of Privacy Practices. Patient name signature Date Northpark Dental Associates 6500 Greenville Ave. Suite 303, Dallas, TX 75206 (214) 696-8096 Fax: (214) 696-8095 Info@NorthParkDental.com AUTHORIZATION FOR RELEASE OF IDENTIFYING HEALTH INFORMATION Patient name Patient number Patient address Patient phone number I authorize the professional office of my dentist named above to release health information identifying me [including if applicable, information about HIV infection or AIDS, information about substance abuse treatment, and information about mental health services] under the following terms and conditions: 1. Detailed description of the information to be released: 2. To whom may the information be released [name(s) or class(es) of recipients]: 2. To whom may the information be released [name(s) or class(es) of recipients]: 3. The purpose(s) for the release (if the authorization is initiated by the individual, it is permissible to state "at the request of the individual" as the purpose, if desired by the individual): 4. Expiration date or event relating to the individual or purpose for the release: It is completely your decision whether or not to sign this authorization form. We cannot refuse to treat you if you choose not to sign this authorization. If you sign this authorization, you can revoke it later. The only exception to your right to revoke is if we have already acted in reliance upon the authorization. If you want to revoke your authorization, send us a written or electronic note telling us that your authorization is revoked. Send this note to the office contact person listed at the top of this form. When your health information is disclosed as provided in this authorization, the recipient often has no legal duty to protect its confidentiality. In many cases, the recipient may re-disclose the information as he/she wishes. Sometimes, state or federal law changes this possibility. [For marketing authorizations, include, as applicable: We will receive direct or indirect remuneration from a third party for disclosing your identifiable health information in accordance with this authorization.] I HAVE READ AND UNDERSTAND THIS FORM. I AM SIGNING IT VOLUNTARILY. I AUTHORIZE THE DISCLOSURE OF MY HEALTH INFORMATION AS DESCRIBED IN THIS FORM. Date Patient signature If you are signing as a personal representative of the patient, describe your relationship to the patient and the source of your authority to sign this form: Relationship to Patient Print Name FINANCIAL POLICY Thank you for choosing us as your dental care provider. At Northpark Dental Associates, we believe you deserve the best care. Anything we say or do will be centered on that philosophy.We are committed to your treatment being successful and maintaining good oral health. Please understand that the payment of your bill is considered part of that treatment. The following is a statement of our FINANCIAL POLICY, which we ask you to read and sign in acknowledgement. PAYMENT FOR SERVICES RENDERED: Patients are responsible for payment of all services rendered on their behalf, or their dependents. Payment is due in full at time of service, unless previous arrangements have been made and are fully understood and agreed upon by both parties. For your convenience we accept Cash, Personal Checks, Visa, Mastercard, Discover and American Express. We offer outside financing through Care Credit. We also offer a 5% prepayment discount for treatment with fees over $1400. We ask that all cleanings and check-ups be paid for at the time of service unless prior arrangements have been made. We ask that you guarantee your account with a credit card if we file insurance for you. If a balance is left over, we will place the balance on the credit card on file after notification. You may also pay in full at the time of service or leave a blank check. CC# Exp. Date Zip Code CVV# RETURNED CHECKS: There will be a $25 return check fee added to your account for insufficient funds or checks returned as non-payable. FINANCE CHARGE: If you do not pay your balance within 30 days of the monthly billing cycle a Finance Charge of 1.5% per month (or a minimum of $5.00 for balances under $100) which is an APR of 18% will be applied to last month's balance. In case of default of payment, you will be responsible for interest, collection costs and attorney fees incurred to collect collection of your account. I HAVE READ AND UNDERSTOOD THE FINANCIAL POLICY. Signature Date INSURANCE POLICY & ASSIGNMENT OF BENEFITS Thank you for choosing us as your dental care provider. Our greatest concern is your complete oral health. Anything we say or do will be centered on that philosophy. We are committed to your treatment being successful and maintaining good oral health. Please understand that the payment of your bill is considered part of that treatment. The following is a statement of our INSURANCE POLICY, which we ask you to read and sign in acknowledgement. By signing below, I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such dental care to third party payors and/or health practitioners. I authorize and request my insurance company to pay directly to the dentist or dental group insurance benefits otherwise payable to me. I understand and agree that my insurance company has rules and guidelines by which my claim may be paid or denied. I understand that I have a contract with my insurance company through my employer or individual plan and that I should know what to expect from my benefits. I further understand that Northpark Dental Associates does not have a contract with my insurance company and therefore cannot guarantee any coverage, benefits, and/or payments from my insurance company. Northpark Dental Associates will attain information regarding my eligibility and benefits with my insurance company, file claims electronically, and accept assignment of benefits; however, since every insurance company plan pays differently on many services they cannot guarantee that the insurance company will pay as estimated. I also understand that my insurance company may determine benefits based on their own set fee schedules or maximum allowable fee schedules and that my insurance company will not share such information with Northpark Dental Associates because they are not in contract with my dental insurance company. understand and agree that I am responsible for the payment of all treatment fees on my account. If my insurance company fails to make payment within 30 days, I will be responsible for the full amount owed to Northpark Dental Associates. understand and agree that I am responsible for any co-pays, the estimated amount not paid by the insurance company, as well as any deductibles that may be inherent to my plan at the time of service. understand that after the insurance company pays Northpark Dental Associates there could still be a balance remaining, for which I am responsible. I agree to pay any unpaid balance in full within 30 days of being billed unless prior arrangements have been made in advance. We will do our best to accommodate your needs and work with you to maximize your dental benefits and create a dental plan that works for you. Printed Name Signature Date NORTHPARK DENTAL ASSOCIATES PAGE OF CONSENTS Diagnosis and Treatment I hereby authorize Dr. Gibbons and/or his designated staff to take x-rays, study models, photographs and other diagnostic aids deemed appropriate by Dr. Gibbons to make a thorough diagnosis of my dental needs. Upon such diagnosis, I authorize Dr. Gibbons and staff to perform all recommended treatment mutually agreed upon by me and to employ such assistance as required to provide proper care. I agree to the use of anesthetics, sedatives and other medication as necessary. I fully understand that using anesthetic agents embodies certain risks. I understand that I can ask for a complete recital of any possible complications. Patient's Signature Date Parent/ Responsible Party Signature Relationship to Patient BROKEN APPOINTMENTS: We strongly encourage all patients to keep their appointments. Failure to give 24 hour notice to cancel or reschedule an appointment will result in a $50 per hour charge to your account. Emergencies are the only exception. (Initials) Photography Consent I hereby give Northpark Dental Associates the absolute right and permission to use my photographs for educational or promotional purposes. The undersigned completely and forever releases any right to present or future compensation in connection with the use of said photographs. Signature Date NORTHPARK DENTAL ASSOCIATES I hereby authorize Northpark Dental Associates to contact me regarding my dental appointments and/or treatment, as needed. I understand they may contact me by phone, text and/or email. I give my permission to leave messages on my home, work or cell phone regarding my appointment times. If I am unreachable you may also leave a message with the following person(s): Signature Date Please enter code above in the field below.