Welcome To

Northampton Dental Group P.C.

The benefits of a happy, healthy smile are immeasurable! Our goal is to help you reach and maintain maximum oral health. Please fill out this form completely. The better we communicate, the better we can care for you.

1. About You

Date
Name
Dr
Mr
Mrs
Ms
I prefer to be called:
Sex:
M
F
Birthdate:
Age:
SS#:
Home Address:
City
State:
Zip:
Email:
Single
Married
Divorced
Widowed
Separated
Home#:
Cell#:
Work#:
Ext:
Employer:
Occupation:
Best time and number to reach you:
Who may we thank for inviting you to our office?
May we mention your name? :
Yes No
Previous Dentist
Last Visit:

2. Spouse/Parent Information

His/Her Name:
Birth Date:
SS#:
Work:
Ext:
Person responsible for account:
Relation:
SS#:
Billing Address:
Work#:
Home#:

6. Medical History

Your current physical health is:
Good
Fair
Poor
Are you taking any prescription/over-the-counter or herbal supplemental drugs?
Y
N
Please list each one:
Have you ever taken Phen-Fen (Redux or Pondimin)?
Y
N
For Women: Are you taking birth control pills?
Y
N
Are you pregnant?
Y
N
week#
Are you nursing?
Y
N
Have you ever had any of the following diseases or medical conditions?
Heart Problems/Conditions
Y
N
Blood Disorders (bleeding problems)
Y
N
Blood Transfusions
Y
N
High Blood Pressure
Y
N
High Cholesterol
Y
N
Stroke
Y
N
Cancer/Chemotherapy
Y
N
Radiation Therapy
Y
N
Diabetes
Y
N
Epilepsy/Seizures
Y
N
Fainting Spells
Y
N
Artificial Joints/Valves
Y
N
hepatitis
Y
N
HIV/AIDS
Y
N
Tuberculosis
Y
N
Psychiatric Problems
Y
N
Acid Reflux/GERD
Y
N
Liver problems
Y
N
Kidney Problems
Y
N
Osteoporosis
Y
N
Hearing/Vision Impaired
Y
N
Nervous Disorders
Y
N
Frequent Headaches
Y
N
Please explain/list any serious medical conditions that you have ever had:
Do you smoke/use tobacco in any form?
Y
N
Previously but quit
Do you drink alcohol?
Never
Occasionally
Weekly
Daily
Do you use street drugs?
Never
Occasionally
Weekly
Daily
What type?

Are you allergic to any of the following?
Y N
Aspirin
Y N
Erythromycin
Y N
Ibuprofen
Y N
Codeine
Y N
Metals
Y N
Penicillin
Y N
Tetracycline
Y N
Local Anesthesia
Y N
Latex
Please list any other drugs/materials you are allergic to:

3. Dental Insurance

PRIMARY
Dental Coverage:
Yes
No
Ins. Co. Name:
Ins. Co. Address:
Ins. Co. Phone:
Group#:
Insured’s Name:
Relation:
SS#:
Birthdate:
Employer:
SECONDARY
Dental Coverage:
Yes
No
Ins. Co. Name:
Ins. Co. Address:
Ins. Co. Phone:
Group#:
Insured’s Name:
Relation:
SS#:
Birthdate:
Employer:

5. Emergency Contact

In case of emergency, is there someone nearby we can contact?
Name:
Relation:
Home#:
Work#:
Cell#:

6. Medical History

Do you have a personal physician?
Yes
No
Physician:
Phone:
Last Visit:
Currently under care?
Yes
No

7. Dental History

Why have you come to the dentist today?
Do you require antibiotics for joint replacement or heart valve
issues before dental treatment?
Yes
No
Are you currently in pain?
Yes
No
Do you have a dry mouth?
Yes
No
Do you require antibiotics for joint replacement or heart valve
dental work?
Yes
No
Do you now or have you ever experienced pain/discomfort
in your jaw joint (TMJ/TMD)?
Yes
No
Your current dental health is:
Good
Fair
Poor
Do you like your smile?
Yes
No
Would you like whiter teeth?
Yes
No
Would you like fresher breath?
Yes
No
How many times a week do you floss?
How many times a day do you brush?
Type of bristles?
Soft
Medium
Hard
Do you grind/clinch your teeth?
Yes
No
Do you snore or have sleep apnea?
Yes
No
OFFICE USE ONLY

Medical / Dental information above has been verbally reviewed with the patient named herein.

Signature:
Date:
comments:

HIPAA Notice of Privacy Practices

Dr. Kelly & Dr. Boynton

THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION, PLEASE REVIEW IT CAREFULLY.

This notice of Privacy Practices describes how we may use and disclose your protected health information (PHI) to carry out treatment, payment or health care operations (TPO) and for other purposes that are permitted or required by law. It also describes your rights to access and control your protected health information. “Protected Health Information” is information about you including demographic information, which may identify you and that, relates to your past, present, or future physical or mental health or condition related to health care services.

Uses and Disclosures of Protected Health Information

Your protected health information may be used and disclosed by your physician, our office staff and others outside of our office that are involved in your care and treatment for the purpose of providing health care services to you, to pay your health care bills, to support the operation of the physicians practice, and any other use required by law.

Treatment:

We will use and disclose your protected health information to provide, coordinate, or manage your health care and any related services. This includes the coordination or management of your health care with a third party. For example, your protected health information may be provided to a dentist to whom you have been referred to ensure that the dentist has the necessary information to diagnose or treat you.

Payment:

Your protected health information will be used, as needed, to obtain payment for your health care services. For example, obtaining approval for treatment may require that your relevant protected health information be disclosed to the health plan to obtain approval for the treatment.

Healthcare Operations:

We may use or disclose, as-needed, your protected health information in order to support the business activities of your dentist’s practice. These activities include, but are not limited to, quality assessment activities, employee review activities, training of dental students, licensing, market and fundraising activities, and conducting or arranging for other business activities. For example, we may call you by name in the waiting room when your dentist or hygienist is ready to see you. We may use or disclose your protected health information, as necessary, to contact you to remind you of your appointment.
We may use or disclose your protected health information in the following situations without your authorization. These situations include: as Required by Law, Public Health issues as required by law, Communicable Diseases: Health Oversight: Abuse or Neglect: Food and Drug Administration requirements: Legal Proceeding: Law Enforcement: Coroners, Funeral Directors, and Organ Donation: Research: Criminal Activity: Military Activity and National Security: Worker’s Compensation: Inmates: Required Uses and Disclosures: Under the law, we must make disclosures to you and when required by the Secretary of the Department of Health and Human Services to investigate or determine our compliance with the requirements of section 164.500.

Other Permitted and Required Disclosures

Will be made only with your consent, authorization or opportunity to object unless required by law.

You may revoke this authorization,

at any time, in writing, except to the extent that your dentist or the practice has taken an action in reliance on the use or disclosure indicated in the authorization.

Your Rights

The following is a statement of your rights with respect to your protected health information.

You have the right to inspect and copy your protected health information.

Under the Federal law, however, you may not inspect or copy the following records; psychotherapy notes; information complied in reasonable anticipation of, or use in, a civil, criminal, or administrative action or proceeding, and protected health information that is subject to law that prohibits access to protected health information.

You have the right to request a restriction of your protected health information.

This means that you may ask us not to use or disclose any part of your protected health information for the purposes of treatment, payment or healthcare operations. You may also request that any part of your protected health information not be disclosed to family members or friends who may be involved in your care or for notification purposes as described in this Notice of Privacy Practices. Your request must state the specific restriction requested and to whom you want the restriction to apply. Your dentist is not required to agree to a restriction that you may request. If a dentist believes that it is in your best interest to permit use and disclosure of your protected health information, your protected health information will not be restricted. You then have the right to use another Healthcare Professional.

You have the right to request confidential communications from us by alternative means or at an alternative location. You have the right to obtain

a paper copy of this notice from us,

upon request,even if you have agreed to accept this notice alternatively i.e. electronically.

You may have the right to have your dentist amend your protected health information.

If we deny your request for amendment, you have the right to file a statement of disagreement with us and we may prepare a rebuttal to your statement and will provide you with a copy of such rebuttal.

You have the right to receive an accounting of certain disclosures we have made, if any, or your protected health information.

We reserve the right to change the terms of this notice and will inform you by mail of any changes. You then have the right to object or withdraw as provided in this notice.

Complaints

You may complain to the Secretary of Health and Human Services if you believe that we have violated your privacy rights. You may file a complaint with us by notifying our privacy contact of your complaint; we will not retaliate against you for filing a complaint. This was published and becomes effective on/or before April 14, 2003

Patient Electronic Signature
Signature
Date

Northampton Dental Group P.C.

Dr. Kelly & Dr. Boynton

Thank you for choosing our office to meet your dental care needs. It is our optimal goal to provide you and your family with the highest quality of dental care, while maintaining a friendly and relaxing environment. In order to keep our standard of care to a level which best serves your needs, we ask you to please observe the following changes to our current office policies.

Cancellation Policy

There are many times that our patients require urgent or emergency treatment and therefore require an appointment as soon as possible. When patients give our office advance notice of their need to cancel a scheduled appointment, this time can then in turn be allocated to these patients in urgent need of treatment. In this way, our office can best serve the needs of ALL of our patients.
Bearing this in mind, our office requires a minimum of 24 hours notice if an appointment must be canceled, 48 hours would be preferable. We do have an answering machine for your convenience so that a message may be left if an emergency comes up. Please be advised that if in the event that no notice is given and the patient does not show up for a scheduled appointment, then a $55.00 fee will be assessed. We do our best to remind our patients of your appointments, but it is ultimately your responsibility to remember your appointment. Please note that this fee is not covered by dental insurance and is the patient’s responsibility.

Dental Benefits/Insurance

Our office will collect your co-payment and bill your insurance using the information given to us. We are happy to do this as a courtesy to you and expect payment from your insurance company within 60 days. Normally, insurance companies will pay within 60 days. However, if we have not received payment from your insurance company after 60 days, the estimated insurance balance will become your responsibility.

Payment Options

To provide you with the best possible care, we expect you to pay your co-payment at the time of service. Please understand that payment of your bill at the time of service is part of your treatment. We work very hard to offer several options that help you afford necessary dental treatment.

  1. To provide you with the best possible care, your co-payment is due at the time of service.
  2. We accept cash, check, or money order.
  3. We accept Visa, MasterCard, or Discover Card for your convenience.
  4. We also offer extended financing through either Care Credit.
  5. A late charge of $5.00 per month will accrue on any account that is over 30 days old.
  6. Any account that goes over 60 days old will be referred for further collection activity and the account will be assessed a $36.00 administrative fee.
  7. Any returned check will be assessed a $30.00 return check fee to cover the bank fees that our office will accrue.
Patient Electronic Signature
Date