Patient Form

Do you have or ever had any of the following :
Do you have any allergies?
Have you ever taken penicillin?
Have you ever had a bad reaction to any drug or medication?
What type of drug or medication?
[WOMEN ONLY] Are you pregnant?
List all the drugs or medications you are currently taking
Are you under the care of a physician ?
Please provide the MD’s name, address and phone number :
In addition to those you have listed, have you taken any of the following medications or drugs within the past year? If yes, please check the appropriate box.
Pharmacy Name
Pharmacy Phone Number

I will assume responsibility of notifying Dr. Harvey and Associates of any changes in my medical history or contact information.

Patient/Guardian Signature
Would you like to have Nitrous Sedation for your dental treatment (s)
Please rate on a scale of 1-5 the importance of each of the following regarding your dental care.(The most important would be #1).
Please rate, as above, what a dentist must do to gain your confidence
Please choose the level of fear you have about dental visits (10 being the highest)
I would like to know about these options available to me for maximizing my comfort and my experience during my visit.(Check all that apply)
Are you concerned about the following? (Check all that apply)

How many times do you wake-up at night?
Do you sleep on your
What would make you choose our dental office over another?
Primary Dental Insurance
Employer name
Employer Tel#
Ins. Co. Name
Insurance Tel#
Subscriber Name
Subscriber Date of Birth
Secondary Insurance/Medical Insurance
Employer Name
Employer Tel#
Subscriber Name
Insurance Company Name
Subscriber Date of Birth
Insurance Tel#

I Certify that I, and/or my dependent(s), have insurance coverage with

Your Name
and assign directly to Upper East Dental Innovations PLLC all insurance benefits, if any, otherwise payable to me for services rendered. I authorize any holder of medical or other information about me to release to such payer or their agents any information needed to determine these benefits for related services. I understand that I am financially responsible for all charges whether paid by insurance. I authorize the use of my signature on all insurance submissions. I hereby authorize Upper East Dental Innovations PLLC, to furnish insurance companies or their representatives information concerning my (my dependents) illness and treatments and I hereby assign to Upper East Dental Innovations PLLC all payments for medical/Dental services rendered by myself or my dependents. The above-named dentist may use my health care information and may disclose such information to the above-named insurance company (is) and their agents for obtaining payment for services and determining insurance benefits or the benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.

Signature of Patient, Parent, Guardian or personal Representative
HIPAA Patient Consent Form

The federal government requireds all medical offices to make patients aware that they have rights regarding the use of their personal health information. Our notice of privacy practices is available for your review at the front desk. By signing this form, you consent to our use and disclosure of protected health information per the Notice of Privacy Practices available to you at our front desk. I understand that I have certain rights to privacy regarding my protected health information. These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA). I understand that by signing this consent I authorize you to use and disclose my protected health information to carry out:

I have also been informed of, and given the rights to review and secure a copy of your Notice of Privacy Practices which contains a more complete description of the use and disclosures of my protected health information, and my rights under HIPAA. I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice. I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment and health care operations, but that you are not required to agree to these request restrictions. However, if you do agree, you are bound to comply with this restriction. I understand that I may revoke this consent at any time, in writing, signed by you.

The Patient understands that:

Relationship to Patient
Understanding Dental Benefits

Note we do not accept nor participate with any DMO/HMO/Union Plans /Medicaid /Discount Plans, Dr. Harvey participates in most PPO insurance plans, and ALL our Specialists and Associates are OUT OF NETWORK. Most plans have a yearly maximum dollar amount that they will reimburse. After you have reached your limit, you will be responsible for full payment.

Your Annual Maximum for the year is

We will bill your dental benefits provider, (usually an insurance company), for services performed at. Though we verify your benefits with your benefits provider, it is not a guarantee of payment and may vary when the actual claim is submitted and processed by your insurance company. As a first-time patient of Upper East Dental Innovations, your first visit you will consist of a Comprehensive Exam, Full Mouth Series of X-rays, Dental Cleaning, Intra Oral Photos, Oral Cancer Screen, Oral Hygiene Instructions, and Fluoride. You will be required to come in at least twice a year for your dental check-up and cleaning. This preserves your dental work we cannot guarantee our work should you choose not come in for regular 6 month recall dental care. Your 6-month appointment will be automatically generated by our scheduling system at the end of every preventative visit. This will assure you have a consistence dental check-up and cleaning as recommended by the ADA. Our goal is to help you maximize your dental benefits. We are not responsible for circumstances beyond our control, such as: Waiting Periods, Frequency, Limitations Yearly Maximums, Missing Tooth Clause, Fee Schedules Downgrades, etc. Regardless of coverage, your estimated co-pay is due in full the day of treatment. The exact payment from your benefits provider may vary so you may receive a bill after we receive a payment from your dental benefits provider (this may take 2 – 6 weeks after treatment). I understand and authorize Upper East Dental Innovations PLLC to take all diagnostic materials needed to make a final diagnosis of dental treatment. Diagnostic materials may include Intra-oral pictures, radiographs, digital radiographs, diagnostic models, photographs and slides. This material may be used for lectures, articles and or publications. I authorize Upper East Dental Innovations PLLC to perform and or administer all forms of treatment, medication and anesthesia that may be necessary. I understand I can obtain this practice’s current Notice of Privacy Practices on request. I hereby acknowledge that I have been provided with a copy of the Notice of Privacy Practices.

Patient/Guardian Signature

Payments are due the day of service. Payments for services can be made by THREE WAYS: 1. Visa, MasterCard 2. Cash, in advance for the entire treatment plan, in full (which you will get 5% off) And 3. Monthly payment plan. Should you have any questions about this, please let us know. I understand that the dental treatment presented to me is my financial responsibility and that all fees for services are due and payable up front as authorized by Upper East Dental Innovations PLLC and or administrator.


When you make your appointment, it is confirmed. To keep our schedule timely and can accommodate all our patients efficiently we ask that you provide 48 hours advanced notice should you need to cancel an appointment. This time has been reserved for you; we schedule appointments so that we never must rush. We do not over schedule. A $100.00 fee will be charged for appointment cancelled less than 48 hours. Account balances are due within 7 days of receipt of a bill. We reserve the right to charge 12% APR for accounts not paid after 14 days. Thank you for your kind cooperation.


X-rays must be requested in writing and will release directly to the patient. A $25.00 administrative fee will be charged for a copy of X-rays/ Records


I give consent to Upper East Dental Innovations PLLC to electronically send x-rays, medical records, and other information pertaining to my patient care at Upper East Dental Innovations PLLC.

Patient/Guardian Signature

If you have any questions or concerns about our office or our policies, please do not hesitate to discuss them with us.We want you to have the best dental care in the most pleasant environment. Your concerns are, therefore, our concerns.