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CONFIDENTIAL

Medical Dental History Form for Adult Patients

PATIENT

CLOSEST RELATIVE

DENTIST

PHYSICIAN

GENERAL INFORMATION

FINANCIAL RESPONSIBILITY

DENTAL INSURANCE

MEDICAL INSURANCE

MEDICAL HISTORY

DENTAL HISTORY

PATIENT HEALTH INFORMATION

FAMILY MEDICAL HISTORY

RELEASE AND WAIVER

Signature

Signature

Arthur B. Silver, DDS. PC Snellville. GA 30078 770 972-6000

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: PATIENT GIVING CONSENT

SECTION B: TO THE PATIENT- PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice

accompanies this Consent. We encourage you to it carefully and completely before signing this Consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy, including any revisions of our Notice, at any time by contacting:

Arthur Sliver, DDS, MSD at 2371 Henry Clower Blvd., Suite A Snellville, GA 30078 770 972-6000

Right to Revoke: You will have the right to revoke this Consent at any time by giving us written notice of your revocation submitted to the Contact listed above. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

SIGNATURE

I, , have had full opportunity to read and consider the contents of this Consent form and your Notice of Privacy. I understand that, by signing this Consent form, I am giving my consent to your use and disclosure of my protected health information to carry our treatment, payment activities and healthcare operations.

Signature

REVOCATION OF CONSENT

I revoke my Consent for your use and disclosure of my protected health information for treatment, payment activities, and healthcare operations. I understand that revocation of my Consent will not affect any action you took in reliance on my Consent before you received this written Notice of Revocation. I also understand that you may decline to treat or to continue to treat me after I revoked my Consent.

Signature

Arthur B. Silver DDS, PC, Snellville, GA 30078 770 972-6000

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

** You May Refuse to Sign This Acknowledgement **

I, , have received a copy of this office's Notice of Privacy Practices.

Signature

Release Authorizing Use of Personal Likeness

I, consent to the use of my personal image and likeness, including but not limited to images representing and depicting the treatment provided to me and the effect thereof, by Silver Smiles for any lawful use Silver Smiles deems appropriate, including for treatment, advertising his/her/its services to the general public (including visa social media and electronic media), illustration, and publication to the public at large for educational purposes.

I hereby relinquish any and all rights to my likeness or any image of me obtained by any photographic or digital means by Silver Smiles during the course of my treatment. I understand that I am entitled to no consideration, remuneration or payment for the use of my image in any advertising, promotional or educational materials.

I understand any image or likeness of me may be altered prior to use if deemed appropriate by Silver Smiles. I understand and agree that I have no right to be consulted about or approve any such alteration before my image is used.

I understand that Silver Smiles will make all reasonable efforts to safeguard my privacy as required by applicable law, including the Health Insurance Portability and Accountability Act of 1996 (HIPPA). I understand, however, that Silver Smiles cannot guarantee my complete privacy in the event my image or likeness is used by third parties.

I understand and agree that Silver Smiles may use information regarding my health condition, including information regarding my diagnosis, course of treatment, my date of birth and/or age and my other relevant medical conditions, in describing the treatment rendered to me as depicted in any image of me.

I understand that Silver Smiles may not and has not conditioned the rendition of treatment to me upon my authorization of the use of my image and/or likeness.

I have read the foregoing in its entirety and understand its terms.

Patient/Guardian Signature:

Provider signature

Insurance Card
Driver's License