Welcome
1 About You
Patient Name
Status
Do you have kids?
2 Insurance Info.

Primary Dental Insurance

Secondary Dental Insurance

3 Account Info

Person ultimately responsible for account

I hereby authorize assignment of my insurance rights and benefits directly to the provider for services rendered. I fully understand I am solely responsible for any balance not paid for by my insurance company (if offered at this office).

4 In Event Of Emergency
Medical Information
1. Are you having any pain or discomfort at this time?
2. Have you been a patient in the hospital during the last two years?
3. Are you now taking any medication or drugs?
4. A. Have you taken any medication or drugs during the last two years?
B. Have you ever taken appetite suppressants i.e. fen-phen (Fenfluramine & Phentermine) or dexfenfluramine or fenfluramine?
5. Have you been under the care of a medical doctor during the last two years or since, taking the appetite suppressant named above?
6. Are you sensitive or allergic to any medications or anesthetics?
7. Indicate which of the following you have had or have at the present. Check "yes or no" to each item.
Allergies or Hives
Allergy to Latex
Allergy to Metal (jewelry, etc.)
Anemia
Angina Pectoris
Arteriosclerosis
Arthritis
Artificial Heart Valve
Artificial Joints (hip, knee, etc.)
Asthma
Blood Transfusion
Bruise Easily
Cancer History
Chemotherapy
Chronic Cough
Cold Sores/Fever Blister
Congenital Heart Disease
Cortisone Medicine
Developmentally Disabled
Diabetic
Drug Addiction
Emphysema
Epilepsy/Seizure
Fainting or dizzy spells
Glaucoma
H.I.V. Positive
Hay Fever
Heart Disease or Attack
Heart Failure
Heart Murmur
Heart Pacemaker
Heart Surgery
Hemophilia
Hepatitis A (Infectious)
Hepatitis B (Serum)
Herpes
High Blood Pressure
Kidney Trouble
Liver Disease
Mitral Valve Prolapse
Nervousness
Radiation Therapy
Rheumatic Fever
Rheumatism
Sickle Cell Disease
Sinus Trouble
Stroke
Thyroid Problems
Tuberculosis
Tumors
Ulcers
Venereal Disease
Yellow Jaundice
A.I.D.S.
8. When you walk upstairs or take a walk, do you ever have to stop because of pain in your chest, shortness of breath, or because you are very tired?
9. Do you ever wake up from sleep and feel short of breath?
10. Have you lost or gained more than ten pounds in the past year?
11. Are you on a special diet?
12. Do you have or have you had any disease, condition, or problem not listed?
13. Do your ankles swell during the day?
14. Do you use more than two pillows to sleep?
FOR WOMEN ONLY
Are you pregnant?
Are you nursing?
Are you taking birth control pills?
I understand the above information is necessary to provide me with dental care in a safe and efficient manner. I have answered all questions truthfully and to the best of my knowledge. I understand that it is my responsibility to advise your office of any changes in the information obtained on this form.
CONSENT:
  1. The undersigned hereby authorizes to order x-rays, study models, photographs, or any other diagnostic aids deemed appropriate by doctor to make a thorough diagnosis of the patient's dental needs.
  2. I also authorize doctor to perform all recommended treatment mutually agreed upon by me and to use the appropriate medication and therapy indicated for such treatment. I understand that using mechanical delivery with anesthetic agents, and/or nitrous oxide analgesia embodies a certain risk, which may include swelling, pain, trismus (restricted jaw opening), infection, bleeding, sinus involvement, and numbness or tingling of the lip, gum or tongue, which rarely is protracted and even more rarely is permanent. I understand that it is my responsibility to report any symptoms to the dentist. Furthermore, I authorize and consent that doctor choose and employ such assistance as deemed fit to provide recommended treatment.
  3. I understand that all responsibility for payment for dental services provided in this office for myself or my dependents is mine, due and payable at the time services are rendered unless other arrangements have been made. In the event payments are not received by the agreed upon dates, I understand that a 1 - 1/2 % finance charge (18% APR) may be added to my account, in addition to any collection charges.
  4. I have received a copy of the Dental Materials Fact Sheet and a copy of the HIPAA Privacy Policy as required by law.
  5. I grant the right to the dentist to release my dental/medical and other information about my dental treatment to third party payors and/or other health professionals, as appropriate under the circumstances.
  6. I grant the dental office permission to use the email address given above to contact me with respect to my dental care.
FOR OFFICE USE:
Smile Analysis
When you see your smile in the mirror, do you like the way your teeth look?
If you had a magic wand, is there something about your smile you would change?
Do you have any black mercury fillings that show, or concern you, that you would like replaced?
Would you like to easily whiten your teeth?
Do you have any old crowns or caps that don't match your natural teeth or you are unhappy about?
Do you clench or grind your teeth?
Are you interested in information about halitosis or bad breath?

Dental Information
Do your gums bleed when your brush?
Are your teeth sensitive to heat or cold?
Are your teeth sensitive to pressure?
Are your teeth sensitive to sweets?
Do you have any fear of dental work?
Patient Acknowledgement of Receipt of Dental Materials Fact Sheet

I, acknowledge I have received from Melissa E. Rinck, D.D.S., a copy of the Dental Materials Fact Sheet dated October 2001.

Covid-19 Patient Screening Form
Do you have a fever or above normal temperature (> 100.0° F)?
Are you experiencing shortness of breath or having trouble breathing?
Do you have a dry cough?
Do you have a runny nose?
Have you recently lost or had a reduction in your sense of smell or taste?
Do you have a sore throat?
Are you experiencing chills or repeated shaking with chills?
Do you have unexplained muscle pain?
Do you have a headache?
Are you experiencing nausea, vomiting or diarrhea?
Even if you don't currently have any of the above symptoms, have you experienced any of these symptoms within the last 14 days?
Have you been in unprotected contact with someone who has tested positive for COVID-19 in the last 14 days? *"Unprotected contact" means without the use of personal protective equipment.
Have you been tested for COVID-19 in the last 14 days?
lf yes, what is the result of the testing?
Are you fully vaccinated for COVID-19?
Have you traveled more than 100 miles from your home in the last 14 days?

Patient signature required at appointment:

I agree to notify the dental practice if within 2 days I become ill with COVID-19 symptoms or test positive for COVID-19. I understand the dental practice has a legal and ethical obligation to inform me if a staff personnel I had close contact with, tested positive for COVID-19 within 2 days.

Acepto dar aviso a la clinica dental si dentro de dos dias presento sintomas de COVID-19 o tengo un resultado positivo de COVID-19. Entiendo que la clinica dental tiene la obligacion legal y etica de informarme si un miembro del personal con el que tuve contacto ha tenido un resultado positivo de COVID-19 dentro de dos dias.


Notice of Privacy Practices
Melissa E. Rinck, D.D.S. • (415) 475-4977
Protecting Your Confidential Health Information is Important to Us
Notice of Privacy Practices

This notice describes how health information about you may be used and disclosed and how you can access this information. Please review it carefully.

Our Promise

Dear Patient:
This notice is not meant to alarm you. Quite the opposite! It is our desire to communicate to you that we are taking seriously Federal law (HIPAA - Health Insurance Portability And Accountability Act) enacted to protect the confidentiality of your health information. We do not ever want you to delay treatment because you are afraid your personal health history might be unnecessarily made available to others outside our office.

Why do you have a privacy policy?

Very good question! The Federal government legally enforces the importance of the privacy of health information largely in response to the rapid evolution of computer technology and its use in healthcare. The government has appropriately sought to standardize and protect the privacy of the electronic exchange of your health information. This has challenged us to review not only how your health information is used within our computers but also with the Internet, phone, faxes, copy machines, and charts. We believe this has been an important exercise for us because it has disciplined us to put in writing the policies and procedures we follow to protect your health information when we use it.

We want you to know about these policies and procedures which we developed to make sure your health information will not be shared with anyone who does not require it. Our office is subject to State and Federal law regarding the confidentiality of your health information and in keeping with these laws, we want you to understand our procedures and your rights as our valuable patient.

We will use and communicate your health information only for the purposes of providing your treatment, obtaining payment, conducting health care operations, and as otherwise described in this notice.

How Your Health Information May Be Used To Provide Treatment

We will use your health information within our office to provide you with dental care. This may include administrative and clinical office procedures designed to optimize scheduling and coordination of care between hygienist, dental assistant, dentist, and business office staff. In addition, we may share your health information with physicians, referring dentists, clinical and dental laboratories, pharmacies or other health care personnel providing you treatment.

To Obtain Payment

We may include your health information with an invoice used to collect payment for treatment you receive in our office. We may do this with insurance forms filed for you in the mail or sent electronically. We will be sure to only work with companies with a similar commitment to the security of your health information.

To Conduct Health Care Operations

Your health information may be used during performance evaluations of our staff. Some of our best teaching opportunities use clinical situations experienced by patients receiving care at our office. As a result, health information may be included in training programs for students, interns, associates, and business and clinical employees. It is also possible that health information will be disclosed during audits by insurance companies or government appointed agencies as part of their quality assurance and compliance reviews.

Your health information may be reviewed during the routine processes of certification, licensing or credentialing activities.

In Patient Reminders

Because we believe regular care is very important to your oral and general health, we will remind you of a scheduled appointment or that it is time for you to contact us and make an appointment. Additionally, we may contact you to follow up on your care and inform you of treatment options or services that may be of interest to you or your family. These communications are an important part of our philosophy of partnering with our patients to be sure they receive the best preventive and restorative care modern dentistry can provide. They may include postcards, folding postcards, letters, telephone reminders or electronic reminders such as email (unless you tell us that you do not want to receive these reminders).

To Business Associates

We have contracted with one or more third parties (referred to as a business associate) to use and disclose your health information to perform services for us, such as billing services. We will obtain each business associate's written agreement to safeguard your health information.

NOTICE OF PRIVACY PRACTICES

Federal law generally permits us to make certain uses or disclosures of health information without your permission. Federal law also requires us to list in the Notice, each of these categories of uses or disclosures. The listing is below.

As Required By Law

We may use or disclose your health information as required by any statute, regulation, court order or other mandate enforceable in a court of law.

Abuse Or Neglect

We may disclose your health information to the responsible government agency if (a) the Privacy Official reasonably believes that you are a victim of abuse, neglect, or domestic violence, and (b) we are required or permitted by law to make the disclosure. We will promptly inform you that such a disclosure has been made unless the Privacy Official determines that informing you would not be in your best interests.

Public Health And National Security

We may be required to disclose to Federal officials or military authorities, health information necessary to complete an investigation related to public health or national security. Health information could be important when the government believes that the public safety could benefit when the information could lead to the control or prevention of an epidemic or the understanding of new side effects of a drug treatment or medical device.

For Law Enforcement

As permitted or required by State or Federal law, we may disclose your health information to a law enforcement official for certain law enforcement purposes, including, under certain limited circumstances, if you are a victim of a crime or in order to report a crime.

Family, Friends And Caregivers

We may share your health information with those you tell us will be helping you with your home hygiene, treatment, medications, or payment. We will be sure to ask your permission first. In the case of an emergency, where you are unable to tell us what you want, we will use our best judgment when sharing your health information only when it will be important to those participating in providing your care.

Workers' Compensation Purposes

We may disclose your health information as required or permitted by State or Federal workers' compensation laws.


Protecting Your Confidential Health Information Is Important To Us
Judicial and Administrative Proceedings

We may disclose your health information in an administrative or judicial proceeding in response to a subpoena or a request to produce documents. We will disclose your health information in these circumstances only if the requesting party first provides written documentation that the privacy of your health information will be protected.

Incidental Uses and Disclosures

We may use or disclose your health information in a manner which is incidental to the uses and disclosures described in this Notice.

Health Oversight Activities

We may disclose your health information to a government agency responsible for overseeing the health care system or health-related government benefit program.

To Avert A Serious Threat To Health or Safety

We may use or disclose your health information to reduce a risk of serious and imminent harm to another person or to the public.

To The U.S. Department of Health and Human Services (HHS)

We may disclose your health information to HHS, the government agency responsible for overseeing compliance with federal privacy law and regulations regulating the privacy and security of health information.

For Research

We may use or disclose your health information for research, subject to conditions. "Research" means systemic investigation designed to contribute to generalized knowledge.

In Connection With Your Death Or Organ Donation

We may disclose your health information to a coroner for identification purposes, to a funeral director for funeral purposes, or to an organ procurement organization tb facilitate transplantation of one of your organs.

If applicable State law does not permit the disclosure described above, we will comply with the stricter State law.

Authorization to Use or Disclose Health Information

Other than is stated above or where Federal, State or Local law requires us, we will not disclose your health information other than with your written authorization. You may revoke that authorization in writing at any time.

PATIENT RIGHTS

You have the following rights related to your health information.

Restrictions

You have the right to request restrictions on the use or disclosure of your health information for treatment, payment, or health care operations in addition to the restrictions imposed by federal Jaw. Our office is not required to agree to your request, but we will endeavor to honor reasonable requests. We generally are not required to agree to a requested restriction. Our office will honor your request that we not disclose your health information to a health plan for payment or healthcare operation purposes if the health information relates solely to a health care item or service for which you have paid us out-of-pocket in full.

Confidential Communications

You have the right to request that we communicate with you by alternative means or at an alternative location. You may, for example, request that we communicate your health information only privately with no other family members present or through mailed communications that are sealed. We will honor your reasonable requests for confidential communications.

Inspect and Copy Your Health Information

You have the right to read, review, and copy your health information, including your complete chart, x-rays and billing records. If you would like a copy of your health information, please let us know. We may need to charge you a reasonable, cost-based fee to duplicate and assemble your copy. If there will be a charge, we will first contact you to determine whether you wish to modify or withdraw your request.

Amend Your Health Information

You have the right to ask us to update or modify your records if you believe your health information records are incorrect or incomplete. We will be happy to accommodate you as long as our office maintains this information. In order to standardize our process, please provide us with your request in writing and describe the information to be changed and your reason for the change.

Your request may be denied if the health information record in question was not created by our office, is not part of our records or if the records containing your health information are determined to be accurate and complete. If we deny your request, we will provide you with a written explanation of the denial.

Accounting of Disclosures of Your Health Information

You have the right to ask us for a description of how and where your health information was disclosed. Our documentation procedures will enable us to provide information on health information disclosures that we are required to disclose to you. Please let us know in writing the time period for which you are interested. Thank you for limiting your request to no more than six years at a time. We will provide the first accounting during any 12-month period without charge. We may charge a reasonable, cost-based fee for each additional accounting during the same 12-month period. If there will be a charge, the Privacy Official will first contact you to determine whether you wish to modify or withdraw your request.

Request a Paper Copy of this Notice

You have the right to obtain a copy of this Notice of Privacy Practices directly from our office at any time. Stop by or give us a call and we will mail or email a copy to you.

We are required by law to maintain the privacy of your health information and to provide to you or your personal representative with this Notice of our Privacy Practices. We are required to practice the policies and procedures described in this notice, but we do reserve the right to change the terms of our Notice. If we change our privacy practices, we will be sure all of our patients receive a copy of the revised Notice. You have the right to express complaints to us or to the Secretary of Health and Human Services if you believe your privacy rights have been compromised. We encourage you to express any concerns you may have regarding the privacy of your information. We will not retaliate against you for submitting a complaint. Please let us know of your concerns or complaints in writing by submitting your complaint to our Privacy Officer.


Thank you very much for taking time to review how we are carefully using your health information. lf you have any questions, we want to hear from you. If not, we would appreciate very much your acknowledging your receipt of our policy by signing and returning this card. We look forward to seeing you again soon!

For additional information about the matters discussed in this notice, please contact our Privacy Officer.