Patient Registration

Patient Consent - Adult

Clinical

1. I authorize Owens Family & Cosmetic Dentistry to perform all recommended treatment, including but not limited to:

• a. All recommended treatment.
• b. Radiographs, study models, photos, and other diagnostic aids or materials (collectively, “Diagnostic Material”) as needed to make a thorough diagnosis.
• c. The use of anesthetics, nitrous oxide, sedatives, and other medication, as needed, and am fully aware that using anesthetic agents involves certain risks, including but not limited to redness and swelling of tissues, pain, itching, vomiting, dizziness, miscarriage, cardiac arrest, drowsiness, and/or lack of coordination.

Financial

2. I am responsible for payment for all services rendered. Should my account become delinquent, I will be responsible for all additional collection costs, including reasonable attorney fees.

Maintaining Appointments

3. A $50 missed appointment fee could be charged to my account for missed appointments or last-minute cancellations by me. I am aware that a 24-hour notice of cancellation is required.

Insurance

4. I authorize the practice to submit claims for payment for services rendered or pre-authorizations necessary to my insurance company, on my behalf and in my name listed as “signature on file,” and assign to the practice the insurance benefits providing assignment is accepted. I am responsible for payment regardless of coverage provided.

5. I am responsible for providing any insurance changes, should they occur, prior to treatment.

HIPAA Acknowledgement

6. I authorize the practice to release to staff, hospitals, health care services plans, insurance companies, self-insurers or their representatives, specialty dentists involved in my care, any and all information, records, and other diagnostic material about my medical history, services rendered, or recommended treatment.

7. I acknowledge receipt of the Notice of Privacy Practices and authorize the practice to use and disclose my protected health information for any clinical financial, and insurance purposes.

8. I authorize ​sharing​ my protected health information with the following individuals who may be involved in my care, and I understand I am responsible to notify the practice of any changes:

Patient Consent - Minor Child

(Effective until age 18 - Tennessee))

The parent or legal guardian must complete this form for a minor, provide consent for dental treatment, and accompany the child during each dental visit. Treatment will not be provided for unattended minors unless it is an emergency. If you wish to designate another adult to be a ​decision-maker​ in your child’s dental care, please complete the Limited Power of Attorney. If you authorize sharing​ protected health information, complete the HIPAA Acknowledgement section below.

Clinical

1. As the parent/legal guardian of the child(ren) listed above, I authorize Owens Family & Cosmetic Dentistry to perform all recommended treatment, including but not limited to:

• a. All recommended treatment;
• b. Radiographs, study models, photos, and other diagnostic aids or materials (collectively, “Diagnostic Material”) as needed to make a thorough diagnosis;
• c. The use of anesthetics, nitrous oxide, sedatives, and other medication, as needed, and am fully aware that using anesthetic agents involves certain risks, including but not limited to redness and swelling of tissues, pain, itching, vomiting, dizziness, miscarriage, cardiac arrest, drowsiness, and/or lack of coordination.

Financial

2. I am responsible for payment for all services rendered. Should my account become delinquent, I will be responsible for all additional collection costs, including reasonable attorney fees.

Maintaining Appointments

3. A $50 missed appointment fee could be charged to my account for missed appointments or last-minute cancellations by me. I am aware that a 24-hour notice of cancellation is required.

Insurance

4. I authorize the practice to submit claims for payment for services rendered or pre-authorizations necessary to my insurance company, on my behalf and in my name listed as “signature on file,” and assign to the practice the insurance benefits providing assignment is accepted. I am responsible for payment regardless of coverage provided.

5. I am responsible for providing any insurance changes, should they occur, prior to treatment.

HIPAA Acknowledgement

6. I authorize the practice to release to staff, hospitals, health care services plans, insurance companies, self-insurers or their representatives, specialty dentists involved in my care, any and all information, records, and other diagnostic material about my medical history, services rendered, or recommended treatment.

7. I acknowledge receipt of the Notice of Privacy Practices and authorize the practice to use and disclose my protected health information for any clinical financial, and insurance purposes.

8. I authorize ​sharing​ my protected health information with the following individuals who may be involved in my care and I understand I am responsible to notify the practice of any changes: