Free State Dental 

Patient Information

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Insurance Information

Policy holder's relationship to you: *

Policy holder's relationship to you: *

HIPAA Release

HIPAA Release: I authorize the release of information including the diagnosis, records, examination rendered, billing and claims information to: **THIS PERSON(S) MAY INQUIRE ABOUT MY TREATMENT, RECORDS, BILLING AND ACCOUNT - PLEASE LIST MORE THAN ONE, IF APPLICABLE *
If unable to reach me, please: *

Medical History

Are you taking any blood thinners? *
Have you ever been told by a physician that you need to take antibiotic pre-medication before dental appointments? Some examples of conditions that require this pre-medication are artificial joints, hardware, heart stints or valves. *

Although dental personnel primarily treta the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive. 
Thank you for answering the following questions.
Are you under a physician's care now? *
Have you ever been hospitalized or had a major operation? *
Have you ever had a serious head or neck injury? *
Are you taking any medications, pills or drugs? *
Do you take, or have you taken, Phen-Fen or Redux? *
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bispohosphonates? *
Are you on a special diet? *
Do you use tobacco? (Tobacco use to include e-cigs and vaping devices) *
Do you use controlled substances? *
WOMEN: Are you Pregnant/Trying to get pregnant?
Take oral contraceptives?
Are you allergic to any of the following? *
Do you have or have you had any of the following? *
To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my health. It is my responsibility to inform Free State Dental of any changes in medical status.

  1. I hereby authorize and direct Galen Van Blaricum D.D.S., Nealy Newkirk D.D.S., and Brad Adams D.D.S., dental hygienists and or dental auxiliaries of their choice, to perform the following dental treatment or oral surgery procedures, including the use of any necessary or advisable local anesthesia, radiographs (x-rays), or diagnostic aides.
  2. Preventive hygiene treatment (prophylaxis) and the application of topical fluoride.
  3. Application of plastic “sealants” to the grooves of the teeth.
  4. Treatment of diseased or injured teeth with dental restorations (fillings, onlays, crowns).
  5. Replacement of missing teeth with dental prosthesis, (bridges, partials, full dentures or implants).
  6. Removal (extraction) of one or more teeth.
  7. Treatment of diseased or injured oral tissue (hard or soft).
  8. Treatment of mal-posed crooked teeth and or oral development or growth abnormalities.
  9. I understand that there are risks involved in this treatment and hereby acknowledge that these risks will be explained to me, that I will have the opportunity to ask questions regarding the treatment and the risks, and that I fully understand the same.
  10. I agree to the use of local anesthesia and the use of Nitrous Oxide/Oxygen analgesia depending on the judgment of the doctor. Nitrous Oxide/Oxygen may occasionally cause nausea and vomiting. I am also aware that the nose piece leaves an indention or ring around the nose which disappears shortly after the procedure. I understand and have been informed of the above risks and complications.
  11. I recognize that during the course of treatment unforeseen circumstances may necessitate additional or different procedures from those discussed. I therefore authorize and request the performance of any additional procedures that are deemed necessary or desirable to oral health and wellbeing in the professional judgment of the dentist.
  12. There are possible risks and complications associated with the administration of local anesthesia. The most common of these are swelling, bleeding, pain, nausea, vomiting, bruising, tingling and numbness of the lips, gums, face and tongue, allergic reactions, hematoma (swelling or bleeding at or near the injection site), fainting, lip and cheek biting resulting in ulceration and infection of the mucosa. I also understand that there are rare potential risks such as unfavorable reactions to medications in respiratory and cardiovascular collapse (stopping of breathing and heart function) and lack of oxygen to the brain that could result in coma or death. I understand and have been informed of the above risks and complications.
  13. I also authorize the doctor to use photographs, radiographs, other diagnostic materials and treatment records for the purposes of teaching, research and scientific publications.
  14. I will be advised that the success of the dental treatment to be provided will require that the patient and the parents follow post –operative and post- care of the dentist and his auxiliaries. I agree that the success of the treatment requires that all post-operative and post care instructions be followed and that regular office visits as scheduled by the dentist and his auxiliaries must be maintained.
  15. I hereby state that I have read and understand this consent, and that all questions about the procedures will be answered in a satisfactory manner, and I understand that I have the right to be provided answers to questions which may arise during and after the course of my treatment.
  16. I further understand that this consent will remain in effect until such time that I choose to terminate it.
  17. By signing I also acknowledge that I have read and have been offered a copy of our Privacy Practices.

Signature: *
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Free State Dental
4111 W 6th Street
Lawrence, KS 66049