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Dr. John M. Hucklebridge - 972-398-2550

Plano and Dallas Dentistry
Patient Forms

At Plano Smile Studio, Dallas cosmetic dentist Dr. John M. Hucklebridge offers a variety of sophisticated treatments. Please fill out these forms to provide Dr. John M. Hucklebridge with information that allows him to assess your oral health and cosmetic dentistry needs and goals.


About you
 Mr. Mrs. Ms. Dr.
Full Name   (required)
Birth Date (mm/dd/yyyy)   (required)
SSN#   (required)
Address 1   (required)
Address 2  
City   (required)
State (required)
Zip   (required)
Marital Status
 Single Married Divorced Widowed Separated
Home Phone  
Mobile Phone   (required)
Work Phone  
Email (required)
Occupation   (required)
Employer   (required)
How did you hear about us?
  (required)
Who may we thank for referring you?
  (required)
More about you…
Spouse/Partner
Full Name  
Children (#)
What are their names?
 
Pets (#)
(we care about them too)
Personal Interests   (required)
Athletic Interests   (required)
Favorite Music   (required)
Favorite Food   (required)
Favorite Movie(s)   (required)
About your benefits…
Primary Dental Insurance (not required)
Name of Insurance
 
Group # (plan, local, or policy #)
 
Address 1  
Address 2  
Phone  
Name of insured
 
Relation to insured
 
Birth Date of insured (mm/dd/yyyy)  
SSN# of insured  
Employer of insured  
Additional Insurance Information (not required)
If you have third party reimbursement, we are happy to help you maximize your benefits. We will ask that you take care of all fees at the time of service. We will submit your claim for you, assigning payment to you.

Due to the great inconsistency in telephone confirmations, our office cannot guarantee the benefit information we are given by your insurance company. We have found that you as the insured are better able to secure information from insurance booklets, human resource personnel, or by directly contacting the insurance company. We recommend that you always note the names of representatives you communicate with, should there be any discrepancies in the benefits provided and those promised to you.

Please do not hesitate to contact our office if you have any questions regarding your dental claims filed by our office. Our qualified staff will be happy to assist you.

To help you better understand your insurance, please call your insurance company and ask the following questions:

Effective date (mm/dd/yyyy)  
Deductible  
Yearly Maximum  
Has the deductible been met  
Benefits Remaining this year  
What is the percentage breakdown for the following:
Preventative % deductible applied?  
Basic % deductible applied?  
Major % deductible applied?  
Ortho % deductible applied?  
What is the frequency on the following:
Cleanings  
Exams  
Bitewing x-rays  
Full mouth x-rays  
Fluoride Treatment  
Age limit  
Are there any waiting periods on any services?
Missing tooth clauses  
Replacement clause  
How many years after replacement?  
Are there any benefits for occlusal guards for TMJ or for brushing habits?
 
About what we can do for you…
How can we help you today?
  (required)
Are you in any pain or discomfort?
  (required)
When was your last dental visit? (mm/dd/yyyy)
  (required)
What don’t you like about your smile?
  (required)
Have you ever had any unpleasant experiences associated with previous dentistry?
  (required)
Does dental treatment make you nervous?
  (required)
What was done at your last dental visit?
  (required)
Have you ever been treated for periodontal gum disease?
 Yes No
If yes, what type of treatment?
 
How often do you brush?
  (required)
What type of brush do you use?
  (required)
How often do you floss?
  (required)
Do you have or have you ever had the following:
 Yes No Bleeding sore gums
 Yes No Unpleasant taste/bad breath
 Yes No Burning tongue/lips
 Yes No Swelling, lumps in mouth
 Yes No Orthodontic treatment (braces)
If yes, when? (mm/dd/yyyy)
 
 Yes No Clicking/popping jaw
 Yes No Change in bite/the way your teeth come together
 Yes No Difficulty in opening or closing mouth
 Yes No Loose teeth
 Yes No Sensitivity to hot
 Yes No Sensitivity to cold
 Yes No Sensitivity to sweets
 Yes No Sensitivity to biting
 Yes No Food packing in between teeth
About your physician…
Full Name   (required)
When was your last visit? (mm/dd/yyyy)
  (required)
How would you rate your current physical health?
 Excellent Fair Poor
Are you currently being treated for any condition?
 Yes No
If yes, explain
 
For women…
Are you taking birth control?
 Yes No
Are you pregnant?
 Yes No
If yes, when are you due? (mm/dd/yyyy)
 
Are you nursing?
 Yes No
About your health…
Have you had any of the following diseases, conditions, or treatments?
 Yes No Abnormal Bleeding
 Yes No Frequent Headaches
 Yes No Mitral Valve Prolapse
 Yes No Alcohol/Drug Abuse
 Yes No Glaucoma
 Yes No Pacemaker
 Yes No Anemia
 Yes No Hay Fever
 Yes No Psychiatric Problems
 Yes No Arthritis
 Yes No Heart Attack
 Yes No Radiation Therapy
 Yes No Artificial Joints/Valves
 Yes No Heart Murmur
 Yes No Rheumatic Fever
 Yes No Asthma
 Yes No Heart Surgery
 Yes No Seizures
 Yes No Blood Transfusion
 Yes No Hemophilia
 Yes No Shingles
 Yes No Cancer
 Yes No Hepatitis
 Yes No Sickle Cell Disease
 Yes No Colitis
 Yes No Herpes/Fever Blisters
 Yes No Sinus Problems
 Yes No Congenital Heart Disease
 Yes No High Blood Pressure
 Yes No Stroke
 Yes No Diabetes
 Yes No HIV/AIDS
 Yes No Thyroid Problems
 Yes No Difficulty Breathing
 Yes No Hospitalized ever?
 Yes No Tuberculosis (TB)
 Yes No Emphysema
 Yes No Kidney Problems
 Yes No Ulcers
 Yes No Epilepsy
 Yes No Liver Disease
 Yes No Venereal Disease
 Yes No Fainting Spells
 Yes No Low Blood Pressure
 Yes No Do you smoke?
Please list any other serious medical conditions you have had
About your medications and any allergies…
Are you taking any prescribed or over-the-counter medications?
 Yes No
If yes, please list
Do you have any allergies?
 Yes No
If yes, please list
Have you ever had an adverse reaction to any of the following
 Yes No Aspirin
 Yes No Latex
 Yes No Codeine
 Yes No Penicillin
 Yes No Anesthetics
 Yes No Antibiotics
 Yes No Ibuprofen
Please explain any other medications or issues we should be aware of

HIPAA Privacy Policies

NOTICE OF PRIVACY POLICIES AND PRACTICES

DEAR PATIENT:

THIS NOTICE DESCRIBES HOW INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

INTRODUCTION:

At Plano Smile Studio we are committed to responsibly treating and using protected information about you. This notice describes the personal information we collect and how and when we use or disclose that information. It also describes your rights as they relate to your protected dental health information. The notice is effective April 14, 2003 and applies to all protected health information as defined by federal regulations.

UNDERSTANDING YOUR DENTAL HEALTH RECORD INFORMATION:

Each time you visit our office, a record of your visit is made. Typically, this record contains information about your visit including your examination, diagnosis, treatment as well as other pertinent dental health data. This information, often referred to as your dental record, serves as a:

  • Basis for planning your care and treatment
  • Means of communication with other healthcare professionals involved in your care
  • Legal documentation outlining and describing the care you received, a tool that you or another payor (your insurance company) will use to verify that services billed were actually provided
  • A tool that we can reference to insure the highest quality of care and patient satisfaction

Understanding what is in your record and how your dental health information is used helps you insure its accuracy, determine what entities have access to your health information and make an informed decision when authorizing the disclosure of this information to other individuals.

YOUR RIGHTS:

You have certain rights under the federal privacy standards. These include:

  • The right to request, in writing, restrictions on the use and disclosure of your protected health information
  • The right to receive confidential communications concerning your health and treatment
  • The right to amend or submit corrections to your protected health information
  • The right to receive a printed copy of this notice

OUR RESPONSIBILITIES:

Our office is required to:

  • Maintain the privacy of your health information
  • We are required by law to provide you with this notice as to our legal duties about privacy practices with respect to information we collect and maintain about you
  • Abide by the terms of this notice
  • Notify you if we are unable to agree to a requested restriction and acknowledge revisions with notifications
  • Accommodate reasonable requests you may have regarding communication of health information via alternative means and locations

As permitted by law, we reserve the right to amend or modify our privacy policies and practices. These changes in our policies may be required by changes in federal and state laws and restrictions. Any updates will be posted in our office. We will not use or disclose your health information without your authorization, except as described in this notice.

HOW WE MAY USE AND/OR DISCLOSE YOUR HEALTH INFORMATION:

We may use your health information for treatment. Your health information may be used by team members or disclosed to other healthcare professionals for the purpose of evaluating your dental health, diagnosing health conditions and providing treatment.

We will use your information for payment. Your health plan may request and receive information on dates of service, the services provided and the condition being treated in order to pay for the services rendered to you.

We will use your information for regular health operations. Your health information may be used as necessary to support day-to-day activities and management of our office. For example: information on the services you received may be used to support budgeting and financial reporting and activities to evaluated and promote quality.

Business associates. In some instances, we have contracted separate entities to provide services to us. These "associates" require your health information in order to accomplish the tasks we ask them to provide. Some examples of these "business associates" might be a collection agency, answering service and computer software/hardware provider.

Communication with family. Due to the nature of our field, we will use our best judgment (ex: emergency situations) when disclosing health information to a family member, other relatives or any other person that is involved in your care or you have authorized to receive this information. We will ask patients 18 years and older to sign a consent to release information to anyone other than themselves.

Healthcare oversight. Federal law requires us to release your information to an appropriate health oversight agency, public health authority or attorney or other federal/state appointee if there are circumstances that require us to do so.

Law enforcement. Your health may be disclosed to law enforcement agencies, without your permission, to support government audits and inspections, to facilitate law enforcement investigations and to comply with government mandated reporting.

Appointment reminders. This practice may use your information to remind you about upcoming appointments. Typically appointment reminders are brief, non-specific messages that may be left on your answering machine or voicemail. This practice also utilizes reminders via US Mail in the form of postcards and letters.

Other uses and disclosures. Disclosure of your health information or its use for any purpose other than those listed above requires your specific written authorization. However, your decision to revoke the authorization will not affect or undo any use or disclosure of information that occurred before you notified us, in writing, of your decision.

Plano Smile Studio
John M. Hucklebridge, D.D.S., F.A.G.D.
4701 W. Park Blvd., Suite #201
Plano, TX 75093
972-398-2550

PATIENT HIPAA CONSENT FORM

I understand that under the Health Insurance Portability and Accountability Act (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used to:

  • Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly.
  • Obtain payment from third-party payers.
  • Conduct normal healthcare operations such as quality assessments and dentist/physician certifications.

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given the right to review such Notice of Privacy Practices prior to signing this consent. I understand that this organization has the right to change its Notice of Privacy Practices from time to time and that I may contact this organization to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment or healthcare operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions.

I understand that I may revoke this consent in writing at any time, except to the extent that you have taken action relying on this consent.
 Yes I agree to the HIPAA Privacy Policy
** This will open the PDF version of our HIPAA Privacy Policy **
 Yes I have read the Privacy Policy
 Yes I agree to the Consent Terms
 Yes I have read the Orientation Form

Dr. John M. Hucklebridge has many years’ experience performing advanced cosmetic dentistry procedures, including placement of porcelain veneers and dental implants. In addition, he has considerable experience treating Dallas teeth whitening and Invisalign clear orthodontics patients. Please visit the respective pages to learn more about these and other procedures performed by Dr. John M. Hucklebridge.



Plano Smile Studio
4701 West Park Boulevard, Suite 201
Plano, TX 75093
(972) 398-2550
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