Medical History Form

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 the dental office of any changes in my medical status. I hereby authorise American Smilel to perform the examination and after explanation, any and all treatment for the above-named patient including radiographs if indicated and consent to such methods, drugs and agents that may be indicated in connection with his/her dental care as well as contacting me with detail of appointments time, planned treatment cost and appointment reminders via email, phone call and/or text message. This consent shall remain in effect until cancelled. I agree to be responsible for payment of all services rendered on my behalf or my dependants.

Heath Care Operations: We may use and disclose your PHI including x-rays, clinical photographs and clinical information for our own health care operations and other health care professionals involved in the provision of healthcare to you.

Business Associates: There are some services provided to our organisation through contracts with business associates, such as laboratory, dental practices or radiology services. We may disclose your PHI to our business associates to enable them to provide their services.

Individuals Involved with Your Care: We may disclose your PHI to family or others identified by you or who are involved in your care or payment for your care.

Legally Required Disclosures & Public Health: We may disclose your PHI as required by law, including to government officials to prevent or control disease, to report child, adult or spouse abuse, to report reactions or problems with products and to report deaths.

Payment: We may use and disclose your PHI to billing and collection agencies, insurance companies and health plans to collect payment for our services.

Changes to this notice: Please note that this consent can be withdrawn at any time