Teledentistry Consent Form Patient Forms & General Informed Consent for Teledentistry Welcome to Lane & AssociatesWe would like to thank you for allowing us to treat you or your loved one as our patient and we are pleased to meet all of your dental needs. We will always do our best to give you the most up-to-date and professional care available! Please read our office policies and procedures listed below. Check off each box stating you agree & understand each statement.Office Policies & Procedures* As a courtesy, Lane & Associates Family Dentistry will file your dental claim with your insurance company. Your deductible and co-pay, or any portion not covered by your insurance company, is due at the time of service. For those patients without insurance coverage, you will be responsible for your payment in full on the day of treatment. Broken appointments: If you are unable to keep your appointment, please inform us at least 24 hours in advance. Two or more broken appointments will lead to you and your family being dismissed from our practice. An unconfirmed appointment may run the risk of being rescheduled. If you have Medicaid, you must have your current Medicaid card with you. Also, if you are 21 years of age or older you are responsible for the $3.00 co-pay. If you do not have a current card, we reserve the right to reschedule your appointment. If you are more than 15 minutes late for your appointment, you may be rescheduled for another day. This will be considered a broken appointment and could result in a $25 fee. All patients under the age of 18 are required to have a parent or legal guardian present with them at each appointment. They will not be seen or treated in the absence of a parent or legal guardian without a signed consent form. Please ask our front desk for more information or to request a form. In the event your payment is past due, you are responsible to pay the cost of collecting any debt owed on your account. This includes all attorney’s fees, late fees, and interest to be charged at one percent per month. By checking each box you agree that you have read and understood all policies listed. How did you select Lane & Associates Family Dentistry?*Family Member/Friend ReferralDentist ReferralCOVID-19 Emergency CommercialAccepts My InsuranceOffers TeledentistryGoogle Search/Google MapsPrint Ad (Magazine/Newspaper)Digital News OutletTV or Other CommercialInstagramFacebookSelect all that apply.Patient InformationPatient Name* First Last Email* Cell Phone*Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Driver's License NumberSSNDate of Birth* Sex*SelectFemaleMaleOtherHeight*Weight*EmployerEmergency Contact Information*Name, Relationship, Cell Phone "(XXX)XXX-XXXX"Responsible Party InformationIs the Patient the Responsible Party?*SelectYes, I am the patient & responsible party.No, another party is responsible for the patient.Responsible Party Name* First Last Relationship to Patient*Responsible Party Cell Phone*Responsible Party Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Responsible Party Email* Responsible Party DOB* Responsible Party Employer*Responsible Party SSN*Insurance InformationDo you have Insurance?*SelectYesNo, I have Lane Advantage.No, I am uninsured/self-paying.Name of Insured on Card* First Last Relationship to Patient*Type "Self-Insured" if you are the patient.DOB of Policy Holder* SSN of Policy Holder*Insurance Company*Insurance Company Phone*Group Number*Policy Number*Insurance Company Address* Street Address Address Line 2 City AlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific State ZIP Code Patient Medical HistoryDental History*Check all that apply. NONE LISTED Currently experiencing dental pain or discomfort Gums bleed when you brush or floss Sensitive Teeth (Hot/Cold/Pressure) Dry Mouth History of Orthodontic Treatment (Braces) History of Periodontal Treatment (Gum) Suffer from Earaches or Neck Pains History of Serious Injury to Head or Mouth Wear Dentures or Partials Brux or Grind Teeth Popping or Clicking Noises in Jaw Sores or Ulcers in Mouth Date of your last Dental Exam (Approx.)* What is the reason for your Teledentistry visit? Is there anything you would like to tell the doctor?*In your explanation please let us know the date of your last dental Xrays taken (if known). Are you now under the care of a physician?*SelectYesNoIf yes, please list your physician's Name, Address, and Phone.*Date of Last Physical Exam (Approx.)* Are you currently being treated for any medical conditions?*SelectYesNoIf yes, please explain what condition is being treated below.*Have you had a serious illness, operation, or been hospitalized in the last 5 years? If so, what was the illness or problem? If not, please type "NA."*Medical History*Please check next to any of the following diseases or problems that apply to your health. If none, check "NONE." NONE Abnormal bleeding AIDS or HIV infection Anemia Angina Arteriosclerosis Arthritis Artificial (prosthetic) heart valve Asthma Autoimmune disease Blood transfusion Bronchitis Cancer/Chemotherapy/Radiation Treatment Cardiovascular disease Chest pain upon exertion Chronic Pain Congenital heart disease (CHD) Congestive heart failure Damaged heart valves Damaged valves in transplanted heart Diabetes Type I or II Eating Disorder Emphysema Epilepsy Excessive urination Fainting spells or seizures G.E. Reflux/persistent heartburn Gastrointestinal disease Glaucoma Heart Attack Heart Murmur Hemophilia Hepatitis, jaundice or liver disease High blood pressure Kidney problems Low blood pressure Malnutrition Mental Health disorders Migraines Mitral valve prolapse Neurological disorders Night Sweats Osteoporosis Other congenital heart defects Pacemaker Persistent swollen glands in neck Previous infective endocarditis Recurrent Infections Repaired CHD (completely) in last 6 months Repaired CHD with residual defects Rheumatic fever Rheumatic heart disease Rheumatoid arthritis Severe or rapid weight loss Sinus Trouble Sleep disorder STD Stroke Systemic lupus erythematosus Thyroid problems Tuberculosis Ulcers Unrepaired, cyanotic CHD Are you currently pregnant or nursing?*SelectYes, I am pregnant.Yes, I am nursing.NoAre you taking birth control pills or hormonal replacements?*SelectYesNoLifestyle: Check any of the following that apply.* Tobacco Use (smoking, snuff, or chew) Vaping Alcohol Use Recreational Drug Use (cannabis, cocaine, etc.) Controlled Substance Use None of the above Allergies*Please list any allergies you have & what your allergic reaction was in the past. If not applicable, please type "NA."Medications*Please list all medications, including vitamins, natural, or herbal preparations and/or dietary supplements below. If not applicable, please type "NA."If asked to come in for an in-office visit, would you consent to a blood test if the Doctor or Staff member suffers a needle stick or puncture wound?*YesNoTeledentistry AcknowledgementMY ACKNOWLEDGEMENTBy checking the following boxes, I am agreeing to the statements listed. I have been informed, understand, and give my consent to medical history evaluation, diagnostic and imaging procedures necessary to determine if comprehensive treatment will be required for my dental needs and appropriate recommendations or referrals for potentially needed treatment. I understand the dentist will not be physically present during my appointment – my consultation and evaluation/diagnosis will be performed via online / live correspondence with the dentist. I certify that I have read and understand the above and that the information given on this form is accurate. I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treating me. I acknowledge that my questions, if any, about inquiries set forth above have been answered to my satisfaction. I will not hold my dentist, or any other member of his/her staff, responsible for any action they take or do not take because of errors or omissions that I may have made in the completion of this form. TELEDENTISTRY I understand that teledentistry means that the dentist will be virtually present during my consultation. I specifically consent to the utilization of photographs/video and the transmission of these images to provide telehealth dental services. I acknowledge that while Lane & Associates uses recommended information security measures, teledentisry requires the use of transmitting patient information over secure internet. I acknowledge that teledentisry may not be appropriate for all clinical situations, and after my visit I may be referred for recommended/required treatment. Teledentistry Consent InformationEMAIL COMMUNICATION/RELEASE OF INFORMATION I authorize Lane & Associates and its affiliates to communicate with me via encrypted email regarding my dental assessment including any diagnosis, follow-up report, images and other medical health information at an email address provided by me. Given I have provided my email during the sign-up process, Lane & Associates can assume that email communications are acceptable to me. ACCESS TO MEDICAL INFORMATION I authorize Lane & Associates and its affiliates to (1) release my insurance company or third party payor or administrator any information they request from my medical/dental record in connection with their settlement of any claim filed for my case and any related review, including quality assurance and utilization reviews; (2) permit representatives of my insurer, third party payor or administrator to review my dental record at Lane & Associates for the purposes of performing quality assurance and utilization reviews in connection with their review of my case; (3) release information requested from my dental record to other dentists, facilities or agencies in order to facilitate the provision of continuing care; and (4) permit affiliated and non-affiliated dental and scientific personnel to review my dental records from time-to-time for training or research purposes; Provided that any such review shall be made in a manner calculated to maintain the confidentiality of my identity. ASSIGNMENT OF INSURANCE BENEFITS I, as subscriber or insured, hereby assign to Lane & Associates all dental and medical insurance benefits applicable to this admission and authorize my insurer or third-party payment program to tender payment of such amounts directly to Lane & Associates or its affiliates. I understand that I am responsible to pay Lane & Associates or its affiliates all charges, co-payments or deductibles remaining after insurance payments and all Lane & Associates charges and professional fees for services and supplies that are not paid for by my insurer or third party payor because they have been prospectively determined to be not covered by my insurance contract or third party payment program. If we do not receive payment from your insurance carrier within forty-five (45) days, we will notify you. Failure of your insurance carrier to reimburse our office within sixty (60) days will result in our billing you directly for the remaining balance. Please remember that you are ultimately responsible for your bill. Please Sign BelowBy signing below, you agree that you have read and understood all statements included in this form. This iframe contains the logic required to handle Ajax powered Gravity Forms.