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(803) 888-2012

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Patient Name*
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Mailing Address*
How did you hear about our office?*

Insurance Information

You may skip this section if we have received your insurance information prior to appointment
Subscriber's Address (if different from above)

Medical History

Do you now, or have you ever had any of the following
AIDS / HIV*
Kidney Disease*
Lupus*
Mitral Valve Prolapse*
Rheumatic Fever*
Spleen Removal*
Anemia*
Arthritis*
Artificial Joints/Implants*
Asthma*
Beta Blocker*
Blood Disease*
Blood Thinners*
Breast Cancer*
Cephalosporin Allergy*
Crohn's Disease*
Diabetes*
Emphysema*
Epilepsy*
Erythromycin Allergy*
Excessive Bleeding*
Fainting*
Glaucoma*
Hay Fever*
Head Injury*
Heart Disease*
Heart Attack / Angina*
Heart Murmur*
Hepatitis / Jaundice*
High Blood Pressure*
Latex Allergy*
Liver Disease*
Mental Disorders*
Motrin Allergy*
Nervous Disorders*
Osteoporosis*
Osteomalacia*
Osteonecrosis of the jaw*
Pacemaker*
Paget's Disease*
Penicillin Allergy*
Radiation Treatment*
Respiratory Issues*
Rheumatism*
Sinus Problems*
Stroke*
Sulfur Allergy*
Tetracycline Allergy*
Thrombocytopenia*
Thyroid Problems*
Tuberculosis*
Tumors*
Are you currently under medical treatment?*
Do you use tobacco products?*
Do you take Blood Thinners?*
Please check if you are allergic or have had any reactions to the following:
Aspirin*
Penicillin*
Latex*
Local Anesthetics (i.e. Novocaine)*
Codeine*
Barbiturates*
Sulpha Drug*
Any metal (i.e. Nickel, Mercury, etc.)*
Others*
Do you take or have you taken any of the following medications or any other Bisphosphonate medications?
Zometa*
Aredia*
Fosamax*
Boniva*
Actonel*
Didronel*
Skelid*
Prolea*

Women Only

Are you pregnant or suspect that you may be pregnant?
Are you nursing?

AUTHORIZATION FOR THE USE AND DISCLOSURE OF PROTECTED HEALTH INFORMATION

I hereby authorize Marc Berger Choice Dentistry to use or disclose my Protected Health Information as described below.

I understand that the information I authorize a person/facility to receive may be re-disclosed and no longer protected by state and federal regulations
Patient's Name*
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Name of Person(s) Authorized to RECEIVE the information*
I understand that by signing this Consent form, I am giving my consent to Marc Berger Choice Dentistry to disclose and discuss my protected health information to carry out treatment, payment activities and health car operations with the following family member.
Name*
Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Compliance Officer.
MM slash DD slash YYYY
Information to be used/disclosed

FINANCIAL POLICY

Full payment is due at the time services are rendered. In the event that a balance exists after an appointment, said balance must be paid within 30 days unless prior arrangements have been made. We realize that temporary financial problems may affect timely payment on an account. If such problems arise, it is the patient's responsibility to contact our billing department promptly for payment arrangements and assistance in management of the account. Any balance remaining after 60 days is subject to referral to collections agency. Patient/Guarantor will be responsible for any costs incurred if account is turned over to a collection agency, including collection fees, attorney fees, and any other associated court costs.

Responsible Party

Person responsible for payment if patient is minor/under the age of 18
Your Name*
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Mailing Address*
I have read, understand and agree to the Marc Berger Choice Dentistry Financial Policy.
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Print Name*

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

PURPOSE OF CONSENT: BY SIGNING THIS FORM YOU WILL CONSENT TO OUR USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION TO CARRY OUT TREATMENT, PAYMENT ACTIVITIES, AND HEALTH CARE OPERATIONS.

Notice of Privacy Practices: You have the right to read our notice of privacy practices before you decide whether to sign this consent. Our notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected healthcare information, and of other important matters about your protected health information.

A copy of our notice accompanies this consent. We encourage you to read it carefully and completely before signing this consent.

We reserve the right to change our privacy practices as described in our "Notice of Privacy Practices", which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to the contact person listed on this form. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation and that we may decline to treat you or to continue treating you if revoke this consent.

I have had full opportunity to read and consider the contents of the consent form and your Notice of Privacy Practices. I understand that by signing this consent form, I am giving my consent to your use and disclosure of health information to carry out treatment, payment activities and health care operations.
MM slash DD slash YYYY
YOU ARE ENTITLED TO A COPY OF THIS CONSENT ONCE SIGNED
You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice at any time by contacting our office at: Telephone (803)888-2012 Fax: (803)888-4695 Email: julieberger@mbchoicedentistry.com Address: 928 Woodrow St, Columbia, SC, 29205

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We look forward to meeting you.

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Marc Berger Choice Dentistry
(803) 888-2012 928 Woodrow Street, Columbia, SC 29205

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