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We are pleased to welcome you to our practice. Please take a few minutes to fill out this form as completely as you can. lf you have questions we'll be glad to help you. We look forward to working with you in maintaining your dental health.
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Patient Information
Responsible Party
Insurance Information
Patient Medical History
Patient Dental History
Authorization and Release
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 dental 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.
Photography Release (Optional)
I hereby authorize St Clair Shores Dentists to publish photographs taken of me for use in the St Clair Shores Dentist's print, online and video-based marketing materials.

I hereby release and hold harmless St Clair Shores Dentists from any reasonable expectation of privacy or confidentiality associated with the images specified above.

I further acknowledge that my participation is voluntary and that I will not receive financial compensation of any type associated with the taking or publication of these photographs or participation in company marketing materials or other Company publications. I acknowledge and agree that publication of said photos confers no rights of ownership or royalties whatsoever.

I hereby release St Clair Shores Dentists, its contractors, its employees, and any third parties involved in the creation or publication of marketing materials, from liability for any claims by me or any third party in connection with my participation.
Our Financial Policy

Thank you for choosing us for your dental needs. We are committed to providing you excellent care. We feel the best thing about our style of dentistry is our commitment to quality. If you've been with our practice a while, you already know our attention to detail and fine materials are second nature to us. But everyone's financial situation is different. And good dentistry won't count for much if it is beyond your means.

We accept major credit cards: Visa, Master Card, American Express and Discover and, if you qualify, we'll work with you to devise a method of payment amenable to us both. Our office also offers Care Credit for interest free payment plans.

We work with most dental insurers. Carriers vary, but we'll try to help you get the most benefit out of your particular policy. We'll file your claim forms for you and answer any questions we can. Our fees reflect our commitment to the quality our patients deserve and are considered usual and customary for the area, regardless of any insurance company's determination. Please keep in mind you are responsible for your total obligation should your insurance benefits result in less coverage than anticipated. We do ask that you pay your copay at each visit

We also offer a reduction in fee, for amounts over $500.00 when paid on day of treatment with cash, check, Visa, Master Card, American Express and Discover cards.

Payment for services is the responsibility of the adult accompanying that minor.

Missed Appointments
Be advised that the policy of this office is to charge for missed appointments unless they are canceled 24 hours in advance.

Financial Consent
The patient (guardian) agrees to be fully responsible for total payment of treatment performed in this office.

I understand and agree to this Financial Policy and Agreement

Patient Consent for Electronic Communication

Our practice communicates with you electronically, By utilizing our practices’ electronic services, you agree that David P. Renaud, D.D.S.,P.C. may send to you any of the following that you indentify as communication that can be sent through the Internet to an email address you designate.

Consent and Agreement

I, in the presence of my dentist or the dental practice’s privacy representative, agree that the practice may electronically communicate with me at the following email address or text messaging.

Informed Consent for Dental Treatment
David P Renaud D.D.S., P.C.
Theresa D. Caruana D.D.S.
Audra Herman D.D.S.

For most people, the need for dental treatment arises at some point in their lives. While the vast majority of dental treatment is completed without incident, in rare cases undesired complications may occur.

Although it is uncommon, small cuts or abrasions may occur while working in and around the mouth. This may be caused by the drill, suction tips, dental/surgical instruments and/or impression trays.

For your comfort during treatment, we may use various combinations of anesthetics, nitrous gas and/or sedatives. For the patients using sedatives, we require they be driven to and from the appointment. We do not knowingly use nitrous gas on pregnant women; however, we NEED to be informed of a pregnancy.

Local anesthetics are the most common form of anesthetics. In the vast majority of cases, it’s used without complications or side effects. There are however, some complications that arise from time to time. Bruising can occur around the injection site, especially when multiple injections are given due to the volume of the solution. It may last 1-2 weeks and could be sore and/or swollen. With lower injections, the possibility of residual numbness can occur in the tongue and lip. The sensory nerve that controls the tongue is close to the path that the needle takes anesthetize the lower teeth. In almost all cases the residual numbness is temporary; HOWEVER, it may take up to 6-8 months to return to normal.

During lengthy dental procedures, patients may be required to keep their mouth open for a long period of time. On certain individuals, this may cause what is generally a temporary case of TMD (Temporomandibular Joint Disorder). A person’s jaw and/or the muscles around it can be sore, painful, make noise, and/or have limited opening. These conditions usually go away within a month.

*This is not a complete list of possible complications.*
Your comfort and satisfaction are our #1 goal.

Thank you,
Drs. Renaud, Caruana, Herman and Staff

**The signature above acknowledges that I have read and understand this disclosure.**

Notice of Privacy
*You may refuse to sign this acknowledgement.


We are required by law to maintain the privacy of protected health information, to provide individuals with notice of our legal duties and privacy practices with respect to protected health information, and to notify affected individuals following a breach of unsecured protected health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect September 1,2013 and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law, and to make new Notice provisions effective for all protected health information that we maintain. When we make a significant change in our privacy practices, we will change this Notice and post the new Notice clearly and prominently at our practice location, and we will provide copies of the new Notice upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.


We may use and disclose your health information for different purposes, including treatment, payment, and health care operations. For each of these categories, we have provided a description and an example. Some information, such as HIV-related information, genetic information, alcohol and/or substance abuse records, and mental health records may be entitled to special confidentiality protections under applicable state or federal law. We will abide by these special protections as they pertain to applicable cases involving these types of records.

Treatment. We may use and disclose your health information for your treatment. For example, we may disclose your health information to a specialist providing treatment to you.

Payment. We may use and disclose your health information to obtain reimbursement for the treatment and services you receive from us or another entity involved with your care. Payment activities include billing, collections, claims management, and determinations of eligibility and coverage to obtain payment from you, an insurance company, or another third party. For example, we may send claims to your dental health plan containing certain health information.

Healthcare Operations. We may use and disclose your health information in connection with our healthcare operations. For example, healthcare operations include quality assessment and improvement activities, conducting training programs, and licensing activities.

Individuals Involved in Your Care or Payment for Your Care. We may disclose your health information to your family or friends or any other individual identified by you when they are involved in your care or in the payment for your care. Additionally, we may disclose information about you to a patient representative. If a person has the authority by law to make health care decisions for you, we will treat that patient representative the same way we would treat you with respect to your health information.

Disaster Relief. We may use or disclose your health information to assist in disaster relief efforts.

Required by Law. We may use or disclose your health information when we are required to do so by law.

Public Health Activities. We may disclose your health information for public health activities, including disclosures to:

- Prevent or control disease, injury or disability;
- Report child abuse or neglect;
- Report reactions to medications or problems with products or devices;
- Notify a person of a recall, repair, or replacement of products or devices;
- Notify a person who may have been exposed to a disease or condition; or
- Notify the appropriate government authority if we believe a patient has been the victim of abuse, neglect, or domestic violence.

National Security. We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody the protected health information of an inmate or patient.

Secretary of HHS. We will disclose your health information to the Secretary of the U.S. Department of Health and Human Services when required to investigate or determine compliance with HIPAA.

Worker’s Compensation. We may disclose your PHI to the extent authorized by and to the extent necessary to comply with laws relating to worker’s compensation or other similar programs established by law.

Law Enforcement. We may disclose your PHI for law enforcement purposes as permitted by HIPAA, as required by law, or in response to a subpoena or court order.

Health Oversight Activities. We may disclose your PHI to an oversight agency for activities authorized by law. These oversight activities include audits, investigations, inspections, and credentialing, as necessary for licensure and for the government to monitor the health care system, government programs, and compliance with civil rights laws.

Judicial and Administrative Proceedings. If you are involved in a lawsuit or a dispute, we may disclose your PHI in response to a court or administrative order. We may also disclose health information about you in response to a subpoena, discovery request, or other lawful process instituted by someone else involved in the dispute, but only if efforts have been made, either by the requesting party or us, to tell you about the request or to obtain an order protecting the information requested.

Research. We may disclose your PHI to researchers when their research has been approved by an institutional review board or privacy board that has reviewed the research proposal and established protocols to ensure the privacy of your information.

Coroners, Medical Examiners, and Funeral Directors. We may release your PHI to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or determine the cause of death. We may also disclose PHI to funeral directors consistent with applicable law to enable them to carry out their duties.

Fundraising. We may contact you to provide you with information about our sponsored activities, including fundraising programs, as permitted by applicable law. If you do not wish to receive such information from us, you may opt out of receiving the communications.

Your Health Information Rights

Access. You have the right to look at or get copies of your health information, with limited exceptions. You must make the request in writing. You may obtain a form to request access by using the contact information listed at the end of this Notice. You may also request access by sending us a letter to the address at the end of this Notice. If you request information that we maintain on paper, we may provide photocopies. If you request information that we maintain electronically, you have the right to an electronic copy. We will use the form and format you request if readily producible. We will charge you a reasonable cost-based fee for the cost of supplies and labor of copying, and for postage if you want copies mailed to you. Contact us using the information listed at the end of this Notice for an explanation of our fee structure.
If you are denied a request for access, you have the right to have the denial reviewed in accordance with the requirements of applicable law.

Disclosure Accounting. With the exception of certain disclosures, you have the right to receive an accounting of disclosures of your health information in accordance with applicable laws and regulations. To request an accounting of disclosures of your health information, you must submit your request in writing to the Privacy Official. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to the additional requests.

Right to Request a Restriction. You have the right to request additional restrictions on our use or disclosure of your PHI by submitting a written request to the Privacy Official. Your written request must include (1) what information you want to limit, (2) whether you want to limit our use, disclosure or both, and (3) to whom you want the limits to apply. We are not required to agree to your request except in the case where the disclosure is to a health plan for purposes of carrying out payment or health care operations, and the information pertains solely to a health care item or service for which you, or a person on your behalf (other than the health plan), has paid our practice in full.

Alternative Communication. You have the right to request that we communicate with you about your health information by alternative means or at alternative locations. You must make your request in writing. Your request must specify the alternative means or location, and provide satisfactory explanation of how payments will be handled under the alternative means or location you request. We will accommodate all reasonable requests. However, if we are unable to contact you using the ways or locations you have requested we may contact you using the information we have.
Amendment. You have the right to request that we amend your health information. Your request must be in writing, and it must explain why the information should be amended. We may deny your request under certain circumstances. If we agree to your request, we will amend your record(s) and notify you of such. If we deny your request for an amendment, we will provide you with a written explanation of why we denied it and explain your rights.

Right to Notification of a Breach. You will receive notifications of breaches of your unsecured protected health information as required by law.

Electronic Notice. You may receive a paper copy of this Notice upon request, even if you have agreed to receive this Notice electronically on our Web site or by electronic mail (e-mail).

Questions and Complaints
If you want more information about our privacy practices or have questions or concerns, please contact us.

If you are concerned that we may have violated your privacy rights, or if you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request.

We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services. 

Our Privacy Official: David Renaud
Telephone: 586-771-5888
Address: 25520 Little Mack
St Clair Shores, Mi 48081