Patient Information

Choose which applies

Insurance Information

Secondary Insurance Information

Referral Information

NOTICE OF PRIVACY PRACTIVE ACKNOWLEDGEMENT - HIPAA

By signing this form, you will consent to our use and disclosure of your protected health information (PSI) for the following purposes:
  • To conduct and plan treatment, including multiple healthcare providers who may be involved in treatment directly or indirectly
  • To obtain payment for services provided to you through third-party payers (insurance companies)
  • To conduct normal healthcare operations such as quality assessments, etc.
I have received/been offered a copy of Southern Minnesota Periodontics, PA's Notice of Privacy Practices (NOOP) containing a detailed description of the uses and disclosures of my PSI.

We reserve the right to change our privacy practices as described in our NOPP. If we change our privacy practices, we will issue a revised NOPP, which will contain the changes. Those changes may apply to any of your PSI that we maintain.

I understand that I have the right to revoke this consent at any time by giving written notice of your revocation submitted to our office. Please be aware that we may decline to treat you or to continue treating you if you revoke this consent.

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​​​​​​​Medical History

GENERAL : Do you require a premedication before dental appointments?
TOBACCO USAGE: Do you smoke?
Do you chew tobacco?
FEMALES: Could you be pregnant?
HAVE YOU EVER HAD?
Please list any other conditions or disabilities you would like our office to know about.
DENTAL HISTORY
How you ever had a scaling and root planning (deep cleaning) done?
Last time your teeth were professionally cleaned:
Type of toothbrush you use?
Bristles