Quintero Periodontics - Dr. David Quintero, Dr. George Quintero & Dr. Jessie Yuan

Patient information

Prefix

*First Name

*Middle Name

*Last Name

Nickname

*Date of birth

Social Security Number

*Gender

Male Female

*Street Address 1

Street Address 2

Apt.

*City

*State

*Zip

*Mobile Phone Number

Alternate Phone Number

*Email

Profession/Business Name

Emergency Contact Details

*First Name

*Last Name

*Mobile Phone Number

Alternate Phone Number

*Relationship to Patient

Dentist Name

First Name

Last Name

Phone Number

Medical Doctor Name

First Name

Last Name

Phone Number

Other Information

*Preferred Pharmacy Name

*Preferred Pharmacy Phone

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Upload the back your insurance card

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Guarantor Information

First Name

Last Name

Relative Phone

Date of birth

Social Security Number

Street Address 1

Street Address 2

Apt.

City

State

Zip

Employer/Business Name

Home Phone

Business Phone

Policies and Practices

Please review each section:

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction, I will not hold my doctor, or any member of his staff, responsible for any errors or omissions that I have made in the completion of this form. I permit the office to communicate with me via text message, email or cell phone at the contact information I provided.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

PUBLICATION OF RECORDS

I authorize that my dental records, slides, x-rays or any other information pertaining to my treatment to be used for the advancement of dentistry and reimbursement purposes. My identity will not be revealed to the general public.

*Sign

*Date

CASE PRESENTATION

I authorize Quintero Periodontics to take and use X-rays and photographs of my dental case for: 1) Educational Purposes: I understand that my X-rays and photographs may be used for educational purposes, including but not limited to presentations for dental students, workshops, and training sessions 2) Research: I consent to the use of my X-rays and photographs for research purposes, which may include studies on periodontal health and treatment outcomes 3) Social Media Presentation: I acknowledge that my X-rays and photographs may be used on social media platforms managed by Quintero Periodontics to share information about dental health and promote office services 4) Website Design: I understand that my X-rays and photographs may be featured on the Quintero Periodontics website to illustrate various treatments and enhance patient education. I understand that my identity will be protected, and my personal health information will be kept confidential in accordance with HIPAA regulations. I also acknowledge that I am not being compensated for the use of these images.

Sign

Date

FEES & PAYMENTS

We make every effort to minimize the cost of your care and will be glad to file any dental insurance you have. We will accept assignment for both primary and secondary insurances. Professional services are rendered and charged to you and all deductibles and fee amounts not covered by insurance are due at the time of treatment. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and they pay a percentage of the charge. It is your responsibility to pay the deductible amount as well as any co-insurances or balances not paid by your insurance company. I acknowledge and agree that any outstanding balances not paid within 120 days treatment provided may be subject to a late fee of 10% of the charge each month after the 120 day grace period. I understand that this late fee will be applied to my account as outlined and that I will receive notification of any charges incurred due to late payment. If applicable, you will be responsible for all collection costs, attorney fees and/or court costs. If you cancel your appointment less than 48 hours in advance, a 20% late cancellation fee will be assessed. All cancellations must be done via phone speaking with a staff member, no voicemail cancellations are permitted. The following signature on file is my authorization for the release of information necessary to process my claim. I assign payment of all dental, medical, and surgical benefits including major medical benefits to which I am entitled to Quintero Periodontics. This assignment will remain in effect until revoked by me in writing.

*Sign

*Date

NOTICE OF PRIVACY PRACTICES

You have the right to read our Notice of Privacy Practices before you decide to sign this consent. Our notice provides a description of our treatment, payment activities, healthcare operations, disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our notice accompanies this consent. We encourage you to read it carefully and completely before signing this consent. We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain. I hereby acknowledge that a copy of the office's Notice of Privacy Practices has been made available to me. I have been given opportunity to ask any questions I may have regarding this notice I have had full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices. I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities, and health care operations. I hereby authorize the release of all medical information when necessary to other providers rendering medical/dental care, as well as to labs that need my information in order to make a diagnosis or fabricate an appliance necessary for my treatment. I have read and understand the above information and confirms acceptance of all policies at Quintero Periodontics.

You may obtain a copy of our Notice of Privacy Practices, including any revisions at any time by contacting: Contact Person: Dr. David Quintero Address: 2098 Teron Trace, Suite 600, Dacula, GA 30019 Telephone: 770-614-8823 Fax: 770-614-8824 E-Mail: [email protected]

*Sign

*Date

RIGHT TO REVOKE

You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the contact person listed above. Please understand that revocation of this consent will not affect any actions taken before we received your revocation, and that we may choose to continue your treatment or decline your treatment.

*Sign

*Date

Quintero Periodontics - Patient Form

Patient information

Emergency Contact Details

Dentist Name

Medical Doctor Name

Other Information

Guarantor Information

Insurance information

Primary Dental Insurance Subscriber

Primary Medical Insurance Subscriber

Primary Dental Insurance Information

Primary Medical Insurance Information

Secondary Dental Insurance Subscriber

Secondary Medical Insurance Subscriber

Secondary Dental Insurance Information

Secondary Medical Insurance Information

Health history

Is there a FAMILY history of

Health History Cont.

Have you had or do you currently have...

Have you had or do you currently have...

Pregnancy and Birth Control

Medications Allergies

Are you allergic or had a reaction to:

Please list any other medications you are allergic to.

Please list any medications you are taking

Medications

Policies and Practices

Please review each section:

PUBLICATION OF RECORDS

CASE PRESENTATION

FEES & PAYMENTS

NOTICE OF PRIVACY PRACTICES

RIGHT TO REVOKE