Talva Grundstrom Joost DMD, DICOI

2022 William Street, Jefferson City,

Missouri 65109 USA

573-634-4414

Patient Information

Thank you for choosing our practice for your dental needs. Please complete this form in ink. If you have any questions or concerns, do not hesitate to ask for assistance. We will be happy to help.

Patient Name:
Date
Soc. Sec. No
Address:
City
State
Zip
Birthdate
Age
Home phone #
Cell phone #
Work phone #
Email
Are you:
Your or your parent's employer
Occupation
Business Address
City
State
Zip
Spouse's or parent's name
Workplace
Work phone #
If you are a student, name of school/ college
City
State
Person to contact in case of emergency
Phone #
Insurance Information (Dental Only)
Name of Insured
Relationship to patient
Birthdate
Social Security #
Date employed
Name of Employer
Work phone #
Address
City
State
Zip
Insurance Co.
Group #
Employer #
DO YOU HAVE ADDITIONAL INSURANCE?

IF YES, PLEASE NOTIFY THE RECEPTIONIST

Previous Dentist
Reason For Changing Dentist
Reason For this Appointment
Medical History
Physician
Date of last visit
Please list all medications you are currently taking:
Women
Are you pregnant?
Nursing?
Taking birth control pills?
Do you have a history of the following?
Describe

MEDICATION ALLERGIES:

Comments
Authorization

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 dentl 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.

I acknowledge in the event of a delinquent account, I may be charged a monthly service charge of 1.5% in addition to all expenses and cost incurred in effort to collect on this account.

Doctor's Signature:

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Date:

NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996 ("HIPAA"), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and physician certifications.

I acknowledge that I have received your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I understand that this organisation has the roght to change its Notice of Privacy Practices from time to time and that I may contact this organisation at any time at the address above to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or health care operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

Patient Name:
Relationship to Patient

Doctor's Signature:

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* Signature is mandatory

Date:

OFFICE USE ONLY

I attempted to obtain the patient's signature in acknowledgement on this Notice of Privacy Practices Acknowledgement, but was unable to do so as documented below:

Relationship to Patient
Initials
Reason