Granite Falls Dental Care
A Family Dental Practice Committed to Wellness
Welcome to our dental office! Our goal and commitment is to provide our patients with the highest quality dental care through
education, prevention and treatment in a pleasant and comfortable environment. Good communication is the key to quality care and
we invite your questions. Please take a few moments to read the following information and familiarize yourself with our office.
Payment at the time of service
We require payment at the time of service and for your convenience we accept VISA, Mastercard, Personal Checks and Cash. We
also offer third party financing options through CareCredit. This plan offers interest-free options and low monthly payments. We can
assist you with these payment plan options, please ask us!
We offer a 5% cash discount to all who pay in full by cash or check on the day of service and a 5% discount for our senior citizens age
62 and older.
Insurance and Insurance Co-Payment Responsibility
We will file your insurance claims on your behalf as a courtesy to you, provided your dental insurance company will assign benefits
directly to us. Having dental insurance is not a guarantee of payment. Your insurance coverage is a contract that is set up between
your employer and the insurance company. Full payment of your account is your responsibility. If payment for completed treatment
is not paid by your dental insurance company within 90 days, we reserve the right to request payment in full for the balance owing on
your account. When your insurance eventually pays, we will gladly refund the difference to you.
If you have dental insurance, we will ask you to make your copayment at the time of service. Your copayment is the dollar amount
that is not paid by your dental insurance plan.
Returned Check Fee
All patients paying for balances via personal check will be responsible for an additional fee of $35 on checks returned from the bank
containing “Non-Sufficient Funds” and/or a stop payment issued on a check payment or credit card payment.
Finance Charges
Finance charges accrue on the unpaid balance beginning on the 60th day after charges are incurred. The interest rate will be 12% per
annum or the maximum allowable according to state law. In the event that the account is referred to collections, the undersigned, or
their agent, will be responsible for payment of interest on the unpaid balance at 1% per month from the date of service, in addition to
collection fees, reasonable attorney fees and court costs.
We request a 48 hour notice to change an appointment. A charge may be applied to your account in the amount of $50 if an
appointment is changed with less than a 48 hour notice, or if you fail to keep your scheduled appointment.
I hereby acknowledge receipt of the above information and understand that I am completely responsible for all fees.
_______________________________________ __________________________________________
_______________
Printed Name
Date
Signed Name
Welcome!
Thank you for choosing our dental healthcare team! We will strive to provide you with the best possible dental care. To help us meet
all your dental healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance, please ask us
we will be happy to help.
Patient Information (Confidential)
Date ____________________
Name __________________________________________________________________ Birthdate ____________________ Home phone _____________________
Address ________________________________________________________________ City ________________________ Cell phone _______________________
Email __________________________________________________________________ State ____ Zip code __________ Social Security ____________________
Check Appropriate Box:
Minor
Single
Married
Divorced
Widowed
Separated
If Student, Name of School/College __________________________________________ City ______________________ State _____
Full time
Part time
Patient’s or Parent/Guardian’s Employer ____________________________________________________________________ Work Phone __ ___________________
Business Address ________________________________________________________ City _______________________ State _____ Zip code _______________
Spouse or Parent/Guardian’s Name _____________________________ Employer _________________________________ Work Phone _____________________
How did you hear about our office? _________________________________________________________________________________________________________
Person to Contact in Case of Emergency ____________________________________________________________________ Phone __________________________
Responsible Party
Name of Person responsible for this account ________________________________________________________ Relationship to Patien t ______________________
Address _____________________________________________________________________________________________ Home Phone ___________________ ___
Email _______________________________________________________________________________________________ Cell Phone _________ ______________
Driver’s License # ________________________________________________________ Birthdate _____________________________________ _________________
Employer __________________________________________________ Work Phone _____________________________ Social Security ____________________
Is this person currently a patient in our office?
Yes
No
For your convenience, we offer the following methods of payment. Please check the option you prefer. Payment in full at each appointment.
Cash
Personal Check
Credit Card
VISA
Mastercard
CareCredit
Other Third Party Financing
Insurance Information
Name of Insured _____________________________________________________________________________ Relationship to Patient ______________________ _
Birthdate ______________________________________________________________________ Social Security __________________________________________
Name of Employer ______________________________________________________________ Union or Local # _______ Work Phone ____ _________________
Address of Employer ____________________________________________________________ City _________________ State _____ Zip Code _____________
Insurance Company _____________________________________________________________ Group # ______________ Policy/ID # _____ __________________
Insurance Company Address ______________________________________________________ City _________________ State _____ Zip Code _____________
Do you have any additional insurance?
Yes
No
If yes, complete the following:
Name of Insured _____________________________________________________________________________ Relationship to Patient ____ ___________________
Birthdate ______________________________________________________________________ Social Security __________________________________________
Name of Employer ______________________________________________________________ Union or Local # _______ Work Phone ____ _________________
Address of Employer ____________________________________________________________ City _________________ State _____ Zip Code _____________
Insurance Company _____________________________________________________________ Group # ______________ Policy/ID # _______________________
Insurance Company Address ______________________________________________________ City _________________ State _____ Zip Code _____________
Patient Medical History
Physician _______________________________________________ Office Phone _________________________________ Date of Last Exam _________ _______
Yes
No
1. Are you under medical treatment now? …………….……
8. Are you allergic to or have had any reactions to the following?
Yes No
2. Have you ever been hospitalized for any surgical
Local anesthetics (for example, xylocaine, novacaine …….……
operation or serious illness within the last 5 years? ….….
Penicillin or other antibiotics ………………………..………….
If yes, please explain ____________________________
Sulfa Drugs ……………………………………………….……..
______________________________________________
Barbituates …………………………………………….………..
3. Are you taking any medication(s) including
Sedatives ………………………………………………….….….
Non-prescription medicine? ………………………..……
Aspirin …………………………………………………….….…
If yes, what medication(s) are you taking? ____________
Any Metals (for example: nickel, mercury, etc.) …………..…..
______________________________________________
Other (please list) ………………………………………….……
______________________________________________
9. Do you have a persistent cough or throat clearing no associated
4. Have you ever taken Fen-Phen/Redux? …………….…...
With a known illness (lasting more than 3 weeks?)
5. Do you use tobacco? ……………………………….……
10. Women only:
6. Do you use controlled substances? ……………….……..
a) Are you pregnant or think you may be pregnant? …………
7. Are you wearing contact lenses? ………………….….….
b) Are you nursing? …………………………………………..
c) Are you taking oral contraceptives? ……………………….
Do you have or have you ever had any of the following?
Yes No
Yes
No
Yes No
High Blood Pressure ………………………
Heart Disease ……………….……..
Chest Pains ……………………………..
Heart Attack ………………….…………….
Cardiac Pacemaker ………………..
Easily winded ………….……………….
Rheumatic Fever …………………………..
Heart Murmur ……………………..
Stroke …………………………………..
Swollen Ankles ……………………………
Angina ……………………………..
Hay Fever/Allergies …………………….
Fainting/Seizures ………………………….
Frequently Tired …………………..
Tuberculosis ………………………...…
Asthma ………………………………….…
Emphysema ……………………….
Radiation Therapy ……………….…….
Low Blood Pressure ………………………
Cancer ……………………………..
Recent Weight Loss …………………...
Epilepsy/Convulsions …………………….
Arthritis ……………………………
Liver Disease …………………………..
Leukemia ……………………………….…
Joint Replacement or Implant …….
Heart Trouble …………………………..
Diabetes …………………………………...
Hepatitis/Jaundice …………………
Respiratory Problems ………………….
Kidney Disease …………………………...
Sexually Transmitted Disease ……..
Mitral Valve Prolapse ………………….
AIDS or HIV Infection ……………….…..
Stomach Troubles/Ulcers ………….
Other ___________________________
Patient Dental History
Name of Previous Dentist and Location _________________________________________________________________ Date of Last Exam ____________________
Yes No
Yes No
1. Do your gums bleed while brushing or flossing? ………………..
8. Do you have frequent headaches? ……… ………………………….
2. Are your teeth sensitive to hot or cold liquids/foods? …………..
9. Do you clench or grind your teeth? ………………………………...
3. Are your teeth sensitive to sweet or sour liquids/foods? ………..
10. Do you bite your lips or cheeks frequently? ……………………….
4. Do you feel pain to any of your teeth? …………………………..
11. Have you ever had any difficult extractions in the past? …………..
5. Do you have any sores or lumps in or near your mouth? ……….
12. Have you ever had any prolonged bleeding following extractions?
6. Have you had any head, neck, or jaw injuries? …………………
13. Have you had any orthodontic treatment? …………………………
7. Have you ever experienced any of the following problems in your jaw?
14. Do you wear dentures or partial s? …………………………………
Clicking ………………………………………………….……
If yes, date of placement ______________________________
Pain (joint, ear, side of face?) ………………………….…….
15. Have you ever received oral hygiene instructions regarding the
Difficulty in opening or closing? ……………………….……
the cure of your teeth and gums? ……………………………….
Difficulty in chewing? ……………………………….………
16. Do you like your smile? ……………………………………………
Authorization and Release
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been
accurately answered. I understand that providing incorrect information can be dangerous to my health. 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 payers 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 that my dental insurance carrier may
pay less than the actual bill for services. I agree to be responsible for payment of all services rendered on my behalf or my
dependents.
X____________________________________________________________________________________________________________________________ _________
Signature of Patient (Or Parent/Guardian if Minor)
STATEMENT OF PRIVACY PRACTICES
Our office is dedicated to protect the privacy rights of our patients and the confidential information entrusted to us. The
commitment of each employee to ensure that your health information is never compromised is a principle concept of our
practice. We may, from time to time, amend our privacy policies and practices but will always inform you of any changes
that might affect your rights.
Protecting your personal Healthcare Information
We use and disclose the information we collect from you only as allowed by the Health Insurance Portability and
Accountability Act and the State of Washington. This includes issues relating to your treatment, payment, and our dental
care operations. Your personal health information will never be otherwise given to anyone-even family members-without
your written consent. You, of course, may give written authorization for us to disclose your information to anyone you
choose, for any purpose.
Collecting Protected Health Information
We will only request personal information needed to provide our standard of quality dental care, implement payment
activities, conduct normal dental operations, and comply with the law. This may include your name, address, telephone
number(s), Social Security Number, employment data, medical history, health records, etc. While most of the information
will be collected from you, we may obtain information from third parties if it is deemed necessary. Regardless of the
source, your personal information will always be protected to the full extent of the law.
Disclosure of your Protected Health Information
As stated above, we may disclose information as required by law. We are obligated to provide information to law
enforcement and governmental officials under certain circumstances. We will not use your information for marketing
purposes without your written consent. We may use and/or disclose your health information to communicated reminders
about your appointments including voicemail messages, answering machines, and postcards.
Patient Rights
You have a right to request copies of your healthcare information; to request copies in a variety of formats; and to request
a list of instances in which we, or our business associates, have disclosed your protected information for uses other than
stated above. All such requests must be in writing. We may charge for your copies in an amount allowed by law. If you
believe your rights have been violated, we urge you to notify us immediately. You can also notify the U.S. Department of
Health and Human Services.
We thank you for being a patient in our office. Please let us know if you have any questions concerning your privacy
rights and the protection of your personal health information.
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)
___________________________________________________________
(Signature)
___________________________________________________________
(Date)
__________________________________________________________________________________________
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy Practices, but
acknowledgement could not be obtained because:
Individual refused to sign
Communications barriers prohibited obtaining the acknowledging
An emergency situation prevented us from obtaining acknowledgement
Other (Please Specify)
__________________________________________________________________________________________
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