Heartland Endodontics & Periodontics logo

Gayle Obermayr, DDS, MS

We are pleased to welcome you to our dental family. Thank you for calling Heartland Endodontics and for giving us the opportunity to provide you with the highest Endodontic care possible. Our team of professionals are dedicated to delivering dental care in a comfortable and caring environment. To us, excellent care means a total commitment to 100% satisfaction for you and your family dentist.

As part of our commitment to all of our patients, we promise to treat you with the respect and understanding that you deserve. We will give you exceptional service by using the most advanced technology to insure excellent diagnostics and treatment.

We know that sometimes our patients are apprehensive about dental treatment. In order to make you as comfortable as possible, please look over Heartland Endodontics website. If you have any questions, please call our office. We will be glad to answer any questions you may have.

Also enclosed you will find our medical history form. We use this form to protect your health. Please bring your photo identification and any dental insurance information along with the completed forms enclosed, to our office upon your first appointment. If you have any questions before your first visit, please do not hesitate to call our office.

Please visit us at Heartlandendodontics.com

4660 Lakeview Drive, Suite 101 | Sebring, FL 33870 | phone: 863.382.9947 | fax: 863.382.8965 | www.heartlandendodontics.com

American Dental Association | American Association of Endodontics | American College of Dentist | Past President of Florida Association of Endodontics

WELCOME TO OUR OFFICE

In order to make your dental care a more personal and complete health service, we ask that you please complete the following information.

* denotes REQUIRED field.


Person responsible for account (if different from above)

PAYMENT INFORMATION

Payment is due in full at the time of treatment (unless prior arrangements have been approved). Our office will file your insurance claim when your treatment is completed so that your insurance company will reimburse you promptly.

I (patient / guardian) understand that I am responsible for payment of fees for services rendered.

Dental Insurance Information

Heartland Endodontics & Periodontics logo

MEDICAL / DENTAL HISTORY

Please select YES or NO to the following medical questions below

MEDICAL / DENTAL HISTORY

Please list all physicians and their specialty:

Please list any current medications you are taking and reason. Include prescriptions, supplements, and over the counter.

Have you experienced an allergic or unusual reaction to any of the following?

I understand that the information that I have given today is correct to the best of my knowledge. I also understand that this information will be held in the strictest confidence and it is my responsibility to inform this office of any changes in my medical status. I authorize the dental staff to perform any necessary dental services that I may need during my diagnosis and treatment with my informed consent.

Consent to the Use and Disclosure of Health Information for Treatment, Payment or Healthcare Operations

I , *, understand that as part of my health care, Heartland Endodontics, PA originates and maintains paper and/or electronic records describing my health and dental history, symptoms, examination and test results, diagnoses, treatment and any plans for future care or treatment. I understand this information serves as:

  • A basis for planning my care and treatment and a means of communicating among the many health professionals who contribute to my care.
  • A source of information for applying diagnosis and surgical information to my bill.
  • A means by which a third-party payer can verify that services billed were actually provided, and
  • A tool for routine healthcare operations such as assessing quality and review the competence of healthcare professionals.

I understand and have been provided with a notice of privacy practices that provide a more complete description of information uses and disclosures. I understand that I have the following rights and privileges:

  • The right to review the notice prior to signing this consent
  • The right to request a restriction on certain uses and disclosures of your information as provided by 45 CFR 164.528

I understand the Heartland Endodontics, PA is not required to agree to the restrictions requested. I understand that I may revoke this consent in writing, except to the extent that the organization has already taken action in reliance thereon. I also understand that by refusing to sign this consent or revoking this consent, this organization may refuse to treat me as permitted by Section 164.506 of the Code of Federal Regulations.

I further understand that Heartland Endodontics, PA reserves the right to change their notice and practices at any time provided such changes are applicable by law, and make the new Notice available upon request.

I wish to have the following restrictions to the use or disclosure of my health information:

I wish to have the following persons access to my health information:

I understand that as part of Heartland Endodontics, PA treatment, payment or health care operations, it may become necessary to disclose my protected health information to another entity, and I consent to such disclosure for these permitted uses, including disclosure via fax. I fully understand and accept the terms of this consent.

Patient's Signature *
Parent / Guardian
Date
Office Use - Received By
Office Use - Date