2011 Houser Street
Muscatine, IA 52761

Patient Registration
Birthdate:
Policyholder DOB:
Secondary Policyholder DOB:
3rd Party Policyholder DOB:

By signing below I authorize Lifetime Dentistry to use my Photo for social media during contests, patient appreciation events, andcompany promotions.

I understand that I am financially responsible for all charges whether or not paid by insurance. I assign all insurance benefits directly to the Doctor otherwise payable to me for services rendered. I hereby authorize the Doctor to release all information necessary to secure the payment of benefits. I authorized the use of this signature on all insurance submissions. I understand that all accounts past due 30 days will accrue interest.I understand estimations are only estimations and it is ultimately my responsibility to know my insurance benefits and my benefitplan.

Date: 
Medical History
Although dental personnel primarily treat 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.

When was your last cleaning?
Have you ever been diagnosed with gum disease?
YesNo
Are you under a physician's care now?
YesNo
Have you ever been hospitalized or had a major operation?
YesNo
Have you ever had a serious head or neck injury?
YesNo
Are you taking any medications, pills or drugs?
YesNo
Do you take, or have you taken, Phen-Fen or Redux?
YesNo
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
YesNo
Are you on a special diet?
YesNo
Do you use tobacco?
YesNo
Have you been out of the country within the last 6 months?
YesNo
Are you allergic to the following:
Acrylic
Asprin
Codeine
Dental Anesthetics
Latex
Metals
Penicillin
Sulfa Drugs
Do you use controlled substances?
YesNo
Do you have, or have you had, any of the following?
AIDS/HIV Positive
Alzheimer's Disease
Anaphylaxis
Anemia
Angina
Arthritis/Gout
Artificial Heart Valve
Artificial Joint
Asthma
Blood Disease
Blood Transfusion
Breathing Problems
Bruise Easily
Cancer
Chemotherapy
Chest Pains
Cold Sores/Fever Blisters
Congenital Heart Disease
Convulsions
Cortisone Medicine
Diabetes
Drug Addiction
Easily Winded
Emphysema
Epilepsy/Seizures
Excessive Bleeding
Excessive Thirst
Fainting Spells/Dizziness
Frequent Cough
Frequent Diarrhea
Frequent Headaches
Genital Herpes
Glaucoma
Hay Fever
Heart Attack/Failure
Heart Murmur
Heart Pacemaker
Heart Trouble/Disease
Hemophilia
Hepatitis A
Hepatitis B or C
Herpes
High Blood Pressure
High Colesterol
Hives or Rash
Hypoglycemia
Irregular Heartbeat
Kidney Problems
Leukemia
Liver Disease
Low Blood Pressure
Lung Disease
Mitral Valve Prolapse
Osteoporosis
Pain in Jaw Joints
Parathyroid Disease
Psychiatric Care
Radiation Treatments
Recent Weight Loss
Renal Dialysis
Rheumatic Fever
Rheumatism
Scarlet Fever
Shingles
Sickle Cell Diseaes
Sinus Trouble
Spina Bifida
Stomach/Intestinal Disease
Stroke
Swelling of Limbs
Thyroid Disease
Tonsilitis
Tuberculosis
Tumors or Growths
Ulcers
Venereal Disease
Yellow Jaundice
Have you ever had any serious illness not listed?
YesNo

By signing below I authorize Lifetime Dentistry to use my Photo for social media during contests, patient appreciation events, and company promotions.

I understand all past due accounts are subject to a finance charge of 1.5% per month or maximum rate allowed by law. The undersigned responsible party promises to pay for services in accordance with the above terms. If, at any time, for any reason, the undersigned is unable to pay for services when due, the undersigned agrees to pay and authorizes Lifetime Dentistry to bill their account finance charges as described above. In the event it becomes necessary for Lifetime Dentistry to incur collection costs or institute suit to collect an amount due under this agreement, the undersigned shall be personally and jointly responsible for charges and legal costs incurred, all additional costs, charges, collection fees and expenses, including reasonable attorneys' fees, if incurred for the collection or otherwise and submits to jurisdiction and venue in Muscatine, Iowa. A fee of $30 will be issued to the undersigned responsible party's account in the event a check is returned for insufficient funds.

I understand estimations are only estimations and it is my responsibility to know my insurance benefits and benefit plan.


VELscope Oral Cancer Screening

In our continual effort to provide you (our patient) with the best possible care, we have integrated an oral cancer screening device called VELscope.

VELscope is a hand held device which emits a safe blue light that causes the tissue in the mouth to fluoresce. Typically our oral cancer screening has involved visually inspecting the mouth and palpating for anything that looks or feels “suspicious.” With the VELscope we can literally see below the surface to the base layer where oral cancer begins, to detect any abnormal changes in the cells. This exam takes about 2 minutes, is painless, and can be performed at your recall/check-up visit. Oral Cancer Facts:

1 North American dies every hour of every day from oral cancer. The number of people developing oral cancer are 3 times higher than those of cervical cancer. In the past, 70% of oral cancers were not diagnosed until the late stages because we did not have this technology. If found in the early stages the 5 year survival rate jumps from 52% to 80-90%. The group who is experiencing the greatest growth in oral cancer diagnosis are not those we typically consider “at risk,” i.e. tobacco and alcohol users, but those who report not using either. One of the causes for this appears to be due to the Human Papilloma Virus (HPV) Because of the importance we place on early detection of oral cancer, Dr. Krystek recommends this screening be performed at least once a year. Our fee for the VELscope exam is $25.00, some insurance companies will cover a portion of the fee. If you have questions regarding insurance for this exam you may contact your Dental Insurance Company or ask our front desk personnel to call on your behalf. If you have any further questions feel free to ask the hygienist caring for you today.

Date:

Acknowledgement of Receipt of Notice of Privacy Practices

I acknowledge that I have been provided a copy of Lifetime Dentistry’s Notice of Privacy Practices, which has an effective date of 09/23/2013 and which describes how my health information may be used and disclosed.

I understand that you have the right to change the Notice of Privacy Practices at any time, that I will be provided a copy of any updated version, and that I may contact you at any time to request a current Notice of Privacy Practices.

My signature below acknowledges that I have been provided with a copy of the Notice of Privacy Practices:

Date:

I hereby authorize Dr. Krystek and the staff at Lifetime Dentistry to take photographs, slides, and/or videos of my face, jaws and teeth.

I understand that the photographs, slides and/or videos will be used as a record of my care and may be used for educational purposes in lectures, demonstrations and professional publications.

I further understand that if the photographs, slides, and/or videos are used in any publication or as part of a demonstration, all reasonable attempts will be made to conceal my identity.

Date:
Date:

We know that as a patient, you have a large array of choices when it comes to picking the right dental practice for you. We appreciate you choosing us as your dental care provider. As a patient, you should expect nothing but the best from your dental office in terms of dental care, a welcoming and friendly atmosphere, and a respectful dental team. We strive to create your ideal office and hope to foster a relationship of mutual respect between patient and provider.

As a patient in our office, we will provide you with:

  • Free Parking
  • Patient amenities menu - blanket, heat and massage chairs, hand dips, jewelry cleaner, chapstick, etc...
  • Soothing atmosphere to reduce anxiety
  • Insurance is submitted for your convenience
  • Available financing
  • State of the art technology
  • Digital x-rays (use 70% less radiation) and intraoral cameras for quick diagnoses
  • Combined dental field experience surpasses 30 years
  • Continuing education in the dental field as well as business and patient care courses
  • Gentle and caring staff
  • General, cosmetic, preventative, implant, and Invisalign dentistry
  • Advanced treatment for gum and bone disease
  • Teeth whitening procedures

As a patient of our office we would appreciate the following:

  • Prompt payment for treatment at time of service
  • At least a 48 hour notification of appointment cancellation
  • On time arrival for appointments
  • Informing office of changes to health, address, insurance, phone number, etc...
  • Treatment of staff members and Dr. Krystek with courtesy and respect
  • Appointment confirmation in advance

I understand the relationship between a dentist and a patient is a very personal one, and it requires compatibility, trust, and mutual respect among many other qualities.


Notice of Privacy Practices

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION.

PLEASE REVIEW IT CAREFULLY.
THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.

OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect (4/14/03), and will remain in effect until we replace it.

We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.

You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.

USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:

Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.

Payment: We may use and disclose your health information to obtain payment for services we provide to you.

Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization and Consent: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization and consent to use your health information or to disclose it to anyone for any purpose. If you give us an authorization and consent, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization and consent while it was in effect. Unless you give us a written authorization and consent, we cannot use or disclose your health information for any reason except those described in this Notice.

To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.

Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law.

Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.

National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).

PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.

Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).

Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.

Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.

Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.

FINANCIAL POLICY
Payment is expected at the conclusion of each appointment, unless other prior arrangements have been made. If you have insurance, your co-payment is due at the conclusion of each visit. We accept cash, checks, and the following credit cards: Visa, Mastercard and Discover.

If your treatment results in a co-pay of $200 or greater, you may make three equal installments, spread out over the course of treatment. For major restorative work such as crowns, bridges, root canals, partials and dentures, the first installment will be due at the first appointment, with the final installment due the day the service is completed. We will accept three post-dated checks, pre-signed bank card vouchers, or pre-authorization on a bank/credit card. If you need long term or extended payments, we encourage you to contact your local bank or credit union to apply for a short-term loan.

An interest charge of 1.5% or 18% APR will be charged on late payments, and delinquent accounts, along with ALL collection costs until remitted in full. Delinquent accounts are turned over to a collection agency and/or taken to small claims court.

The Iowa Check Law is enforced. A $20.00 charge will be assessed on all returned checks. There is a three times face value allowable charge or 2FC ($2.00 finance charge per month).

For accounts with a balance of over $100, we ask that payment be made in full before any subsequent elective treatment be scheduled.

As a service to our patients and their families, we will submit your insurance claim to your insurance company TWICE. However, the ultimate responsibility for payment of dental services lies with the patient or responsible party.

I understand what is discussed is kept confidential. Any disclosure of information will only be done with my written consent.

My signature authorizes the release of information necessary to process claims, Section 12 on the HFCA 1500 form. My signature authorizes payment of dental benefits to be paid to Dr. Holly Krystek, D.D.S., P.C. for services rendered.

I agree to be financially responsible, with or without the benefit of insurance, for all charges. I understand the above stated terms and agree to the financial liability. If the patient is a minor, the parent or guardian accompanying them is responsible for payment.

I understand that if I have a problem with the service, I should contact Dr. Krystek immediately.

QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or have questions or concerns, please contact us. If you are concerned that we may have violated your privacy rights, or you disagree with a decision we made about access to your health information or in response to a request you made to amend or restrict the use or disclosure of your health information or to have us communicate with you by alternative means or at alternative locations, you may complain to us using the contact information listed at the end of this Notice. You also may submit a written complaint to the U.S. Department of Health and Human Services. We will provide you with the address to file your complaint with the U.S. Department of Health and Human Services upon request. We support your right to the privacy of your health information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.

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