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Required by law

Please leave blank if the address is the same as mailing address

Do you have (or have you had) any of the following diseases, problems, or symptoms?

Consent to Treatment

The undersigned consents to radiographs (x-rays), laboratory procedures, anesthesia, diagnostic tests, dental treatment, or other procedures rendered to the patient under the supervision of dental faculty. Although the undersigned may elect to undergo certain specific procedures, without adequate diagnosis or treatment plan Fairfield Dental Clinic may decline to treat the patient.

Privacy Practices

Fairfield Dental Clinic's Notice of Privacy Practices is available to the undersigned via our website or in paper form by request. the undersigned consents to the use and disclosure of his/her health information to carry treatment and health care operations. In order to assist in the improvement of dental care, the undersigned authorizes representatives of Fairfield Dental Clinic to use all or part of the patient's record including written records, radiographs, photographs, videotapes, and laboratory reports for teaching so long as the patient is not identified by name in connection therewith. The undersigned has the right to revoke consent at any time by written notice; however we may decline to treat the patient if this consent is revoked.

Patient Rights and Responsibilities

The undersigned hereby acknowledges that Fairfield Dental Clinic's patient Right and Responsibilities is available to him/her via paper form.

Financial Agreement

The undersigned agrees, where he/she signs as agent or as patient, he/she herby individually obligates himself/herself to pay for treatment received at the Fairfield Dental Clinic in accordance with the regular rates and terms of Fairfield Dental Clinic. Failure to pay for services in a timely manner may jeopardize the patient's access to routine dental care. In the event the patient's account is transferred to a bad debt collection agency the undersigned may be responsible for reasonable attorney's fees and collection expenses.

Minors and Dependent Adults

The parent (or legal guardian) of patients under the age of 18 (or dependent adults) must be registered as the guarantor; the guarantor's name and physical address is required. Either parent may be held responsible for payment of treatment rendered to their minor child or dependent adult. Fairfield Dental Clinic's policy is to bill the parent/legal guardian who presented the minor/dependent adult for treatment. The same applies to minors/dependent adults of divorced parents.

Insurance

Fairfield Dental Clinic submits to insurance as a courtesy to our patients; balances after insurance are billed to the guarantor. Ultimately, the guarantor is responsible for payment, regardless of the insurance carrier's consideration. Insurance Claims for services by pre-doctoral and graduate student are submitted under the name of a faculty member, whose name will appear on insurance documents.

The undersigned authorizes Fairfield Dental Clinic to submit claims (on the patient's behalf) to insurance, Medicare, Medicaid, or other third party payer(s) and to disclose health information to the extent necessary to obtain payment. The undersigned also assigns benefits paid by insurance, Medicare, Medicaid, or other third party payer(s) directly to Fairfield Dental Clinic. In consideration of the dental services provided, the undersigned assigns to Fairfield Dental Clinic any benefits to which the undersigned may be entitled to receive, including without limitation any such benefits due or claims the undersigned has under or pursuant to a benefit plan governed under ERISA, 29 USC sec. 101 et seq.
I have reviewd the Fairfield Dental Clinic Financial Policy as stated above and I understand and accept responsibility of cooperating with these policies. I understand that I will be responsible for financial balances resulting from treatment received that in not paid by my insurance company, Medicare, Medicaid, or any third party agency. My signature acknowledges that I understand and accept the above Fairfield Dental Clinic agreement.

With your permission, we may discuss your health information with a person(s) you designate. Your authorization allows dental providers and staff members at Fairfield Dental Clinic to discuss you health history, dental treatment, finances and appointments (including scheduling) with a designated adult such as a family member, friend, dental or medical practitioner outside of Fairfield Dental Clinic. Please consider listing your emergency contact.

I expressly permit Fairfield Dental Clinic to communicate my Protected Health Information (PHI) via email to the e-mail address indicated on my patient registration form, patient record , or this form. This permit also applies to any email that the Fairfield Dental Clinic may send to my referring dental/medical provider, if appropriate.

Email Risks and Your Responsiblity

If you agree to permit the Fairfield Dental Clinic to use e-mail to communicate with you, you should be aware of the following risks and/or your responsibilities:

As the internet is not secure or private, unauthorized people may be able to intercept, read, and possibly modify email you send or are sent by Fairfield Dental Clinic.

You must protect your e-mail account, password and computer against access by unauthorized people.

Since e-mails can be copied, printed, and forwarded by people to who you send e-mails, you should be careful regarding who you send e-mails

Conditions for the use of e-mail

By Consenting to use of e-mail with Fairfield Dental Clinic, you agree that:

The Fairfield Dental Clinic may forward e-mails as appropriate for diagnosis, treatment, reimbursement, and other related reasons. Fairfield Dental Clinic employees, dental staff and agents, other than the recipient, may have access to e-mails that you send. Such access will only be to persons who have a right to access your e-mail to provide services to you.

Fairfield Dental Clinic will not forward e-mails to independent third parties without you prior written consent, except as authorized or required by law.

You should not use e-mail to communicate with Fairfield Dental Clinic if there is an emergency or where you require an answer in a short period of time.

If you e-mail requires or asks for a response, and you have not received a response within a reasonable time period, it is your responsibility to follow up directly with Fairfield Dental Clinic.

You should carefully consider the use of e-mail for communication of sensitive medical information, such as, but not limited to, information regarding sexually transmitted diseases, AIDS/HIV, mental health, developmental disability, or substance abuse.

Fairfield Dental Clinic reserves the right to save your e-mail and include your e-mail or information contained within your e-mail in your dental record

Instructions

You should immediately inform Fairfield Dental Clinic if you change your e-mail address

If you wish to withdraw your consent to communicate by e-mail, you must send an e-mail to Fairfield Dental Clinic stating such

Acknowledgement and Agreement

Fairfield Dental Clinic will use reasonable means to protect the privacy of the patient's health information. However, because of the risks outline above, Fairfield Dental Clinic cannot guarantee that e-mail will be confidential. Additionally, Faifield Dental Clinic will not be liable for improper disclosure of your health information that is not caused by Fairfield Dental Clinic's intentional misconduct.

By signing below, I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communications of e-mail between Fairfield Dental Clinic and me, and consent to the conditions outlined herein, as well as any other instructions that Fairfield Dental Clinic may impose to communicate with me by e-mail. Any questions i may have had wer answered. I understand that this consent is valid until such time as I revoke the consent as outlined above, except to the extent that a person who is to make a communication has already acted in reliance upon this authorization.