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“I never thought I would enjoy going to the dentist, but I really do. You’re the best!”
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Welcome! We are excited to see you for your first appointment in what we hope will be a long-term “friendly family” relationship. We love people and we look forward to helping you with your comprehensive dental care needs. We also promise to do all we can to make you feel relaxed and comfortable during your visit.
During your new patient visit, we will assess your complete oral health status. A full dental and periodontal evaluation will be performed. The doctor and staff will recommend any necessary treatment and they will review your plan with you prior to beginning any treatment. The steps to achieve and maintain good oral health are different for everyone. There are always options for success.
When you arrive for your first visit, please provide completed dental health and insurance information forms which will allow us to begin your dental treatment. The forms are available below for downloading, or, if you are not comfortable with digital resources, we’ll have the blank forms ready for you to fill out when you arrive. In that case, please arrive about 15 minutes before your scheduled appointment to allow enough time to fill out the forms and share important information.
Your initial exam will last approximately one hour. We’ll provide you with oral hygiene instructions along with suggestions to help you care for your teeth. In most cases, we will also clean your teeth on this first visit and provide you with an evaluation that will outline any existing dental problems, along with suggested treatment.
Let’s get started!
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“Quality is far more important to us than quantity! With so many dental offices to choose from, we know that it is more important than ever to make certain our office is genuinely different by offering you the best quality dental care service and caring personal attention available.”
–Adam Naler, D.D.S.
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Please download and fill out the required Patient Forms below in order for us to more quickly and accurately understand your oral health history and your dental care needs.
After downloading and opening the digital forms, you may wish to print them and fill them out by hand; or, if your computer has the ability, you may fill out the documents digitally before printing. You may bring the forms with you to your first appointment or you may choose to scan the completed forms and then email a copy to us as an attachment prior to your appointment.
If you have trouble downloading any of the required forms, don’t worry. We also have printed versions at the dental office for your convenience.
If you have any questions, please don’t hesitate to call us at: 816.858.5343.
You may email the completed form(s) as an attachment to: firstname.lastname@example.org
- Patient Information Form
- Health History Form
- Patient Consent Form
- Financial Policy Form
- Notice of Privacy Practices
Our privacy pledge to you is this: except for the reasons listed below, we will not share any private information that personally identifies you with any third party, unless we have your consent.
The only exception to this policy is that we are required to reserve the right to disclose personal information to protect our rights or property, or to disclose information to law enforcement or other government officials as we, in our sole discretion, believe necessary or appropriate (including as required by law or at the request of government regulators or other law enforcement officials or the courts). We will have no duty to notify you of disclosures for these reasons.
Click here for a printable version of our Notice of Privacy Practices or read the policy below.
Notice of Privacy Practices
This notice describes how health information about you may be used and disclosed and how you can get access to this information. Please review it carefully. The privacy of your health information is important to us.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect April 14, 2003, and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend, or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters.)
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice.)
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. (You must make your request in writing.) Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.
QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us.
If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, You may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.
We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
The bottom line: We’re good listeners. We care. We’re great at what we do.
Come by for a visit. Contact us online or call us now to make an appointment at: 816.858.5343
We look forward to seeing you soon.