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8888 Ladue Road Suite 200
St. Louis, MO 63124
Phone: (314) 727-6676 Fax: (314) 721-0930
info@wolkendental.com
www.wolkendental.com


Patient Intake Form & Health History 

We are pleased to welcome you to Wolken Family Dental! Please complete, electronically sign, and submit these forms back to us. Feel free to call us if you have any questions. We are happy to help.

01 Your Information
02 Dental & Medical History
03 Office Policies
04 HIPAA Policies
05 General Consent
Patient Information



Women








OFFICE POLICIES

If you need to reschedule
Please be conscientious with your appointments

  • Our clinical team reserves each appointment just for you and we don’t overbook. It’s important that you’re on time.

  • We understand that life happens, but if you do need to change your appointment please let us know at least 24 hours in advance.

  • Appointments that are canceled less than 24 hours in advance will be subject to a cancellation charge of $50.00 per hour of time reserved.

  • We make every effort to contact you to confirm your appointment as a courtesy, however, once an appointment is scheduled, it is the responsibility of the patient to arrive on their scheduled time.




Payment arrangements
Payment is expected the day service is rendered
  • We accept cash, money order, certified check, Care Credit, Visa/MasterCard, Discover, and American Express.
  • We offer payment plans and interest-free financing for approved patients through Care Credit
We Submit Insurance Claims as a courtesy to all our patients; however, any portion that the insurance does not cover is the patient’s responsibility. We want to help you understand your insurance and maximize your benefits, but also we want to make sure you’re aware insurance coverage isn’t a guarantee of payment. If for any reason your insurance does not pay us what was estimated, the responsibility for payment will be yours.

  • We accept most major PPO plans towards payment. We file claims for all plans, in or out of network, but ultimately the patient is responsible for any unpaid balances from their insurance carrier.


Our honor code
Honor Yourself.  Take a moment to honor yourself. You've set aside time today to look after your health and well-being; for that alone you deserve a round of applause! Our entire team is grateful for the opportunity to help you. We've designed an experience to give you freedom to express your wellness goals without shame. It's by honoring your unique story, whatever it may be, that we can truly get to know you and your needs. We simply ask for honesty, and we'll do everything we can to help you reach your goals.
Honor your word. The choices you make in treatment are commitments to yourself and your caregivers. When you choose an appointment time, we ask that you respect the time that is reserved just for you. Please arrive on time so we can give you the quality care that we've promised. Remember that treatment is important for your wellness. If you're using insurance and it doesn't pay quite what we estimated, we have several flexible financial options for you to help manage the cost of your care - because ultimately your health is the most important thing. 
Honor others. You deserve to receive care in a tranquil and pleasant environment, so we ask that you help maintain a positive atmosphere. Please be conscious of your behaviour and avoid acting in ways that could negatively affect other patients or caregivers. We're all in this together!
Acknowledgement



HIPAA Policy
Notice of Privacy Practices: Use and Disclosure of Health Information Protected under HIPAA.
Effective May 1, 2014
This document provides a summary of how health care information about you may be used and disclosed and how you can obtain access to this information.

We understand that information about you and your health is personal. We are committed to protecting your health information. It is our policy that the privacy of your protected health information (PHI) not be compromised while still allowing necessary access to assure that the health care you receive is appropriate and of the highest possible quality.

We pledge to you that we will protect the confidentiality of information provided to us. Your information will be used in the following manner, known as Treatment, Payment, and Healthcare Operations (TPO):
1. To provide dental treatment and/or services.
2. To facilitate payment by third party payers, when appropriate, for health care treatment you receive.
3. To facilitate the mechanisms which allow the operation of our facility.

In every use of your information, we will be responsible custodians of your PHI and adhere to the standards set forth in the legislation, which created these privacy practices. We recognize that all patients have the right to privacy in matters relating to their health, and we will not use your PHI for uses other than TPO related to health care without your express permission.

You have the following rights regarding the medical information we maintain about you:
1. Access, upon request, to information that may be used to make decisions about your care.
2. To request restrictions or limitations on the PHI we disclose about you for treatment, payment or health operations. While we are not required to agree to your request, if we do agree, we will comply with the restrictions unless the information is needed to provide emergency treatment.
3. To request that we amend the PHI we maintain about you if you believe that the information we have about you is incorrect or incomplete.
4. To request an accounting of disclosures we have made for uses other than our own.
5. To request confidential communications; i.e., that we communicate with you in a certain manner or at a certain location.
6. To receive a paper copy of this notice.

All members of our staff are committed to adhering to the conditions set forth in this notice of privacy practices. Any violation will be grounds for disciplinary action. We reserve the right to change this policy in the future; such changes will be available to all patients.

Authorized Disclosures: Wolken Family Dental will not use or disclose your PHI without your prior authorization. You can later revoke that authorization in writing to allow any future use and disclosure. The authorization will be obtained from you by Wolken Family Dental.

Should you believe that your privacy rights have been violated, you may file a complaint with this facility or with the State oversight department; all complaints must be submitted in writing. You will not be penalized for filing a complaint.
Acknowledgement

No Expiration Until Required by Law

Consent Form for General Dental Procedures

As part of your healthcare team, we want to be honest and informative. We’re giving you this form to start things out on the right foot…

We believe in empowered patients, making informed decisions. Complications can occur and we are dedicated to helping our patients understand any potential risks and make informed decisions regarding any treatment recommendations. Please don't hesitate to ask any questions regarding your treatment plan.

It’s important that you follow our advice regarding medication, pre and post treatment instructions and referrals to specialists. Please return for all of your scheduled appointments and follow ups. Not following our advice could increase your chances of a poor outcome.

It is imperative that you provide us with accurate information before, during and after your treatment. Certain medical conditions can create a risk of serious complications. If you have a heart condition or heart murmur, please tell us so we can consult with your physician if necessary. Every time we see you, it’s important you let us know about any new medicines you’re taking or any changes to your health history. Please also be sure to provide us with an accurate list of any drug allergies you have.

You are an important part of the treatment team! Please report any problems or complications you experience. 

Please don’t sign this form or agree to treatment until you have read, understood, and accepted each paragraph stated above. Be certain all of your concerns have been addressed to your satisfaction before commencing treatment. Never hesitate to ask us questions, that’s what we’re here for!

Acknowledgement