New Patient Forms - Advanced Dentistry
Transcription
New Patient Forms - Advanced Dentistry
Date: REGISTRATION FORM Thank you for expressing your confidence in choosing our practice! We look forward to assisting you with your dental needs. Please fill out this form in ink only. If you have any questions regarding this form do not hesitate to ask for assistance. We will be happy to help. Patient Name: ________________________________________________ Birth Date: First Last SS#:_____________________________ DL#:____________________ Sex: Male Marital Status: Single Married Divorced Widowed Partnered Spouse/Guardian Name: Text Message 1 day before appts? Home Address: ______________________________________City/State/Zip: Home Phone: ______________________ Cell: ______________________ Work: Email Address: What is the best way to contact you? Home Cell Email Work Employer Name: _____________________________________ Occupation: Address: ____________________________________ City/State/Zip: Female Yes No Whom may we thank for referring you? RESPONSIBLE PARTY Name of person responsible for account: ___________________________________ Relationship: DOB: ______________ Age: _______ SS#:_______________________ Phone: Address: _______________________________________ City/State/Zip: Employer Name: __________________________________ Work Phone: *Please list an Emergency Contact not living with you. Name: Phone: Relationship: PRIMARY DENTAL INSURANCE INFORMATION Subscriber’s Name: _______________________________________ Relationship: DOB: _____________ SS#:__________________________ ID#: Insurance Company: _______________________________________Group #: Ins Phone#:_________________________ Ins Address: Employer’s Name: _________________________________ Work Phone: Do you have Secondary Dental Insurance? YES NO Subscriber’s Name: _______________________________________ Relationship: DOB: _____________ SS#:__________________________ ID#: Insurance Company: _______________________________________Group #: Ins Phone#:_________________________ Ins Address: Employer’s Name: _________________________________ Work Phone: I hereby authorize payment directly to the dental office of the group insurance benefits otherwise payable to me. I understand that I am responsible for all costs of dental treatment. I hereby authorize the dental office to administer such medications and perform such diagnostic, photographic and therapeutic procedures as may be necessary for proper dental care. The information on this page and the dental/medical histories are correct to the best of my knowledge. I grant the right to the dentist to release my dental/medical histories and other information about my dental treatment to third party payers and/or other health care professionals as is beneficial for payment or dental care. Signature of Patient or Parent/Guardian Date MEDICAL HISTORY Date: ____________________ Patient Name: _______________________________________________________ DOB: _____________________ Check () if you have or have had problems with any of the following: AIDS/HIV Positive Yes No Diabetes Yes No Neurological Problems Yes Allergies Yes No Emphysema Yes No Pacemaker Yes No Anemia Yes No Endocarditis Yes No Psychiatric Care Yes No Angina Yes No Epilepsy Yes No Radiation Treatment Yes No Anxiety Yes No Fainting or dizziness Yes No Respiratory Disease Yes No No No Arthritis, Rheumatism Yes No Fibromyalgia Yes No Rheumatic Fever Yes Artifical Heart Valves Yes No Glaucoma Yes No Scarlet Fever Yes No Artifical Joints Yes No Headaches Yes No Shortness of Breath Yes No Asthma or Hay Fever Yes No Heart Attack Yes No Seizures Yes No Back Problems Yes No Heart Murmur Yes No Sinus Trouble Yes No Bleeding abnormally, with Yes No Heart Disease Yes No Skin Rash Yes No extractions or surgery Yes No Hemophilia Yes No Special Diet Yes No Blood Disease Yes No Hepatitis Type ______ Yes No Stroke Yes No Blood Transfusion Yes No Herpes Yes No Swollen Feet or Ankles Yes No Cancer Therapy Yes No High Blood Pressure Yes No Swollen Neck Glands Yes No No Chemical Dependency Yes No Jaundice Yes No Thyroid Problems Yes Chemotherapy Yes No Jaw Pain Yes No Tonsillitis Yes No Circulatory Problems Yes No Kidney Disease Yes No Tuberculosis Yes No Claustrophobia Yes No Leukemia Yes No Tumor or growth on Yes No Congenital Heart Lesions Yes No Liver Disease Yes No head or neck Yes No Contact Lenses Yes No Low Blood Pressure Yes No Ulcer Yes No COPD Yes No Measles or mumps Yes No Venereal Disease Yes No Weight Loss, unexplained Yes No Yes No Cortisone Treatments Yes No Mitral Valve Prolapse Yes No Cough, persistent or bloody Yes No Nasal Obstruction Yes No Medications routinely used in dental treatment may interact with both prescription and a number of illegal street drugs. Check () the medications you are presently taking, medications you have taken in the past, or medications you have had an adverse reaction to: Presently Taken in History of Taking the Past Reaction Presently Taken in History of Taking the Past Reaction Cortisone or Other Steroids Coumadin, Heparin, Warfarin or other blood thinners Dilantin Diuretics (water pills) Fen-phen (Lonimin, Adipex, Fastin, Phentermine, Pondimin, Fenfluramine, Redux, Dexfenfluramine) Heart Medications such as Digoxin, Nitroglycerin or Digitalis Ibuprofen (Motrin) Anesthetics, Locally Injected Anesthetics, General Antacids Anti-anxiety Medications Anti-depressants Antihistamines Daily Aspirin Regimen Birth Control Pills Blood Pressure Medications Codeine, Demerol or Other Analgesics Presently Taken in History of Taking the Past Reaction Insulin or Diabetes Medications Sedatives or Tranquilizers Sleeping Pills (Barbiturates) Thyroid Medication such as Synthroid, Levoxyl or Levothyroxine Tylenol (Acetominophen) Adverse reaction to any other medication or drug Yes No Please specify ______________________________ ___________________________________________ ___________________________________________ List the other medications you are curretnly taking and what condition you are taking them form Include vitamins, supplements, herbs and over the counter medications. Medication Condition Check () your current use of: Prescribing Doctor Tobacco Yes No Yes No Yes No Yes No Yes No Packs per day ________ Alcohol, Beer, Wine Pharmacy Name Drinks per day ________ Phone Women: Are you pregnant? Yes Have you had any serious illnesses or surgeries? No Nursing? Yes If yes, describe Yes No No Street Drugs Times per day ________ Caffeine Cups per day _________ Do you have any other health needs you should bring to our attention? High Stress Reason _____________ To the best of my knowledge, the above information is complete and correct. I understand that it is my responsibility to inform my doctor if I, or my minor child, ever have a change in health. Signature of Patient, Parent, Guardian or Personal Representative Date Please print name of Patient, Parent, Guardian or Personal Represtative Relationship to Patient DENTAL HISTORY Date: Patient Name: DOB: Dental Clinic: Dentist's Name: Street Address: City/St/Zip: Phone: Date of Last Appt: Date of Last X-Rays: Why did you leave your previous dentist? Check () if you have or have had problems with any of the following: Bad Breath Yes No Chew on one side of mouth Yes No Bleeding gums Yes No Tobacco use Yes No Gums swollen or tender Yes No Chewing on foreign objects Yes No Sores, blisters, growths on lips or mouth Yes No Fingernail biting Yes No Burning sensation on tongue Yes No Thumb sucking Yes No Biting cheeks or lips Yes No Tongue thrusting Yes No Dry mouth Yes No Pain on brushing teeth Yes No Mouth breathing Yes No Loose or broken teeth Yes No Chewing Yes No Loose or broken fillings Yes No Swallowing Yes No Food collection between the teeth Yes No Talking Yes No Sensitivity to cold Yes No Prominent gag reflex Yes No Sensitivity to hot Yes No Snoring Yes No Sensitivity to sweets Yes No Periodontal treatment Yes No Sensitivity when biting Yes No Pyorrhea or trench mouth Yes No Stained teeh Yes No Orthodontic Treatment Yes No Grinding or clenching teeth Yes No Wisdom teeth extracted Yes No Clicking or popping jaw Yes No Bite problems Yes No Jaw pain or fatigue Yes No Missing teeth Yes No Opening or closing jaw Yes No Shifting position of teeth Yes No Pain around ear Yes No How often do you brush? How often do you floss? How often do you have your teeth cleaned? How often do you change toothbrushes? PATIENT GOALS What is your goal for dental treatment today? Are you in discomfort today? Yes No Are you pleased with the appearance of your teeth? Do you like your smile? Yes No Does dental treatment make you nervous? Yes If no, please explain: No If no, please explain: Yes Have you been pleased with your previous dental care? If yes, please explain: No Yes No Have you ever had a bad experience in a dental office? If so, please explain: How can we help improve your teeth and smile? Signature of Patient Date Patient Agreement We would like to take this opportunity to welcome you to Advanced Dentistry. The following is an agreement between Advanced Dentistry and you (or the individual taking responsibility for payment if someone other than you). By executing this agreement, you are agreeing to pay for all services received. Treatment Plans During your appointment at Advanced Dentistry you will be given a treatment plan estimate that will give you a financial guideline to your treatment. Although we make every effort to minimize changes to your treatment plan, changes may arise after treatment is initiated. As this occurs, a new treatment plan will be written and presented to you. Please know that treatment plans do not represent additional appointments that cannot be foreseen, such as emergency appointments, denture relines, temporary crown replacements, etc. These additional appointments are billed on a “per appointment” basis, depending on procedure. We DO NOT list them on your treatment plan, as not all patients may need them. Appointments Please know that Advanced Dentistry generally schedules around 2-4 weeks in advance for appointments, unless you are a patient of record experiencing a dental emergency. Therefore, we ask that you provide appropriate notice before cancelling or rescheduling an appointment so that we may offer the time to another patient seeking dental care. Advanced Dentistry requires 2 days’ notice to be given during regular office hours (8:00am-5:00pm) to avoid a $60 per half hour charge. Messages left on the machine overnight less than 2 days prior to an appointment are not accepted as proper notice. Advanced Dentistry will not schedule patients that have missed or cancelled two appointments without proper notice. Insurance As a service to you, we will do our best to help you receive the maximum benefits available under your private or employer purchased policy. Please be aware that most insurance companies will not cover all dental costs, but may pay a fixed allowance for certain procedures. As a courtesy, we will send all dental claims to your insurance company at your request, but we require payment on all services to be paid up front regardless of insurance coverage. Any over payment made by your insurance will be sent either to you directly by your insurance company or issued as a refund by Advanced Dentistry. Although we may estimate what your insurance company may pay, it is the insurance company that makes the final determination of your eligibility and insurance benefits. We are happy to assist you with any further insurance needs you may have. Payment Terms We accept cash, checks, Visa, Master Card, Discover and American Express. We do not do any in office financing, however we do work with both CareCredit™ and Lending Club Patient Financing. For more information, please contact our office. There will be a charge of $35 for all returned checks and all future payments will require cash or credit card payment. All fees for dental services are due when rendered. Overdue Accounts/Finance Charges Advanced Dentistry makes every effort to ensure that all accounts are paid at the time services are rendered. If prior payment arrangements are made, payments are due in accordance with that agreement. Should a payment become 30 days past due, a late fee will be assessed at $35 per month, occurring on the 1st of the month. If no payment arrangements have been made the entire balance is due within 25 days of the received statement, according to Oregon law. The same late fees and timelines apply. After 90 days of non-payment on an account, the account may be sent to collections with a final rebill fee of $35. Prior to this, all necessary steps will be taken to collect on any overdue account, in accordance with the collection laws of Oregon. In an effort to keep our costs at a reasonable rate we do not have an in-house collections department. Due to that fact, we contract with an agency. If we have to refer your account to a collection agency, you agree to pay any and all costs in association with that agency. You also agree to assume all costs incurred for court and lawyer fees, should the account move to litigation. Litigation may also require that any treatment you received in our office may become a matter of public record. Transferring of Records Records requests other than the transfer of x-rays to another provider will need to be in writing. In cases where your records exceed 10 pages, require color copies, and/or are delivered by a delivery service, a reasonable fee may be applied. Any costs incurred by Advanced Dentistry to forward these documents to you, another doctor, or organization will be forwarded on to you and will need to be paid prior to the release of your records. If you are having records transferred from another facility to ours, you authorize us to receive all relevant information on your behalf. Assignment and Release For those individuals with insurance, your signature below hereby authorizes your insurance benefits to be paid directly to Advanced Dentistry. It also authorizes the doctor to release any information required for payment and processing of this claim. Please sign below to acknowledge your understanding of the information contained herein. ________________________________________ Printed Name _______________________________________________ _ Signature _______________________ Date Effective Date: Your signature on this agreement indicates you agree to all of the terms and conditions contained in the agreement. The agreement is effective as of the date signed and dated above ACKNOWLEDGEMENT OF RECEIPT OF PRIVACY PRACTICES NOTICE Include This Acknowledgement In the Patient’s Records Please sign and date below to indicate that you have received a copy of our Privacy Policy notice. Your signature simply acknowledges that you received a copy of this notice. Print Name: Signature: Date: Patient’s Authorized Representative If patient is under 18 years of age, or you are consenting to the care of another If a personal representative signs this authorization on behalf of the individual, the representative states that he/she has the legal authority to sign this acknowledgement on behalf of the following patient: Patient’s Printed Name: Personal Representative’s Printed Name: Relationship to Individual: Personal Representative’s Signature: Date: Good Faith Effort to Obtain Acknowledgement of Receipt If patient or patient’s representative refuses to acknowledge receipt Describe the reason why the individual would not sign this form: NOTICE OF PRIVACY PRACTICES As Required by the Privacy Regulations Created as a Result of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) THIS NOTICE DESCRIBES HOW CERTAIN HEALTH INFORMATION ABOUT YOU, AS A PATIENT OF THIS PRACTICE, MAY BE USED, DISCLOSED, AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. In conducting our business, the doctors and staff of Advanced Dentistry creates records regarding you and the treatment and services that we provide to you. We are committed to abide by all applicable laws regarding the protection of your individually identifiable health information (“health information”). This notice is intended to provide information to you about our privacy practices, our legal duties, and your rights concerning your health information. This notice is effective as of August 11, 2007 (the “Effective Date”) and its scope applies to all records containing your health information that are retained or created by us after the Effective Date. We reserve the right to change our privacy practices and the terms of this notice at any time, and such new privacy practices will be effective for any records that we have created or maintained in the past or that we may create or maintain in the future. Before we make any material changes in our privacy practices, however, we will make our new notice available upon request. OUR USES AND DISCLOSURES OF HEALTH INFORMATION For Treatment: We may use your health information to provide you with dental treatment and related services. We may disclose your health information to other dental offices, dentists, physician offices, laboratories, providers, agencies, facilities, pharmacies, transport companies, family members, or other health care providers and their staff involved in providing health related treatment, services or care to you. For example, we may disclose your health information to a pharmacy to write a prescription for you. We may communicate with you about or recommend possible treatment options or alternatives that may be of interest to you. We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters) or informational, educational purposes or promotional materials such as practice newsletters. For Payment: We may use and disclose your health information (e.g., x-rays, billing statements, etc.) to persons or entities (e.g., insurance companies, family members, third party payers, health plans) so that you (or we as the case may be) can be reimbursed for treatment and services we provide to you. For Health Care Operations: We may use and disclose your health information for our health care operations. Health care operations include quality assessment and improvement activities, reviewing the competence of health care professionals, evaluating practitioner and provider performance, conducting educational or training programs, accreditation, certification, licensing or credentialing activities or to detect or prevent health care fraud and abuse, contractual obligations, patients’ claims, grievances or lawsuits, health care contracting, legal, tax, or business planning and development, business management and administration, promotional programs, the sale of all or part of Advanced Dentistry to another entity, underwriting, claims management and other insurance activities. We may disclose your health information to another health care provider or organization to support some of their health care operations. Relatives, Caregivers and Personal Representatives: We may disclose your health information to a family member, friend, personal representative, or other person you identify that is involved in your dental or health care or with payment for your dental or health care. Unless you have otherwise provided us the authorization to do so, before we disclose your health information to such people, we will provide you with an opportunity to object to our use or disclosure. If you are not present, or in the even of your incapacity or an emergency, we will disclose your medical information based on our professional judgment of whether the disclosure would be in your best interest. We may 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. We may use or disclose information about you to notify or assist in notifying a person involved in your care, of your location and general condition. Health Related Benefits and Services: We may contact you about benefits or services that we provide. Disaster Relief Efforts: We may use or disclose your health information to a public or private entity authorized by law or by its charter to assist in disaster relief efforts. News Gathering Activities: We may contact you or one of your family members to discuss whether or not you want to participate in a media or news story (e.g., a news reporter working on a story about dental health may ask whether any patients undergoing some sort of specific dental treatment may be willing to interviewed). Public Benefit: We may use or disclose your medical information as authorized by law for the following purposes deemed to be in the public interest or benefit, including without limitation, for public health activities, including disease and vital statistic reporting, child abuse reporting, FDA oversight, and to employers regarding work-related illness or injury; to report adult abuse, neglect, or domestic violence; to health oversight agencies; to coroners, medical examiners, and funeral directors; to an organ procurement organizations; to avert a serious threat to health or safety; in connection with certain research activities; and to the military and to federal officials for lawful intelligence, counterintelligence, and national security activities. As Authorized or Required By Law: We will disclose health information when authorized or required to do so by applicable law, including without limitation, in response to court and administrative orders and other lawful processes; to law enforcement officials pursuant to subpoenas and other lawful processes, concerning crime victims, suspicious deaths, crimes on our premises, reporting crimes in emergencies, and for purposes of identifying or locating a suspect or other person; to correctional institutions regarding inmates; and as authorized by state workers’ compensation laws. Lawsuits and Similar Proceedings: In connection with lawsuits or other legal proceedings, we may disclose health information about you in response to a court or administrative order, or in response to a subpoena, discovery request, warrant, summons, or other lawful process. We may disclose health information to courts, attorneys, and court employees in the course of litigation, arbitration, or other judicial or administrative proceedings. Law Enforcement: If asked to do so by law enforcement, and as authorized or required by law, we may release medical information: to identify or locate a suspect, fugitive, material witness, or missing person; about a suspected victim of a crime if, under certain limited circumstances, we are unable to obtain the person’s agreement; about a death suspected to be the result of criminal conduct; about criminal conduct at Advanced Dentistry; and in case of a medical emergency, to report a crime; the location of the crime or victims; or the identity, description or location of the person who committed the crime. Coroners, Medical Examiners and Funeral Directors: In most circumstances, we may disclose medical information to a coroner or medical examiner. This may be necessary, for example, to identify a deceased person or to determine cause of death. We may also disclose medical information about patients of Advanced Dentistry to funeral directors as necessary to carry out their duties. National Security and Intelligence Activities: As authorized or required by law, we may disclose medical information about you to authorized federal officials for intelligence, counterintelligence, and other national security activities. Other Uses of Health Information: Not every specific use or disclosure of your health information is listed in this notice. Unless you provide us (or have already provided us) with separate written authorization to use or otherwise disclose certain personal or health information for certain purposes, all of the ways we are permitted to use and disclose health information will fall within one of the following categories. PATIENT RIGHTS Your health information that we have created and maintain is the property of Advanced Dentistry. You have the following rights, however, regarding your health information that we maintain. Right to Inspect and Copy: You have the right to look at or get copies of your health information, with certain exceptions. You may make reasonable requests that we provide copies in a format other than photocopies. We will use the format you request unless it is unduly burdensome to do so. You must make a request in writing to obtain access to your health information by sending a letter to the Privacy Officer identified at the bottom of this notice. If you request copies, we will charge you a fee for these services that may include labor, duplication costs, and postage. 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 may – but are not required to – 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 more information about fees. Right to Amend: You have the right to request that we amend your health information if you believe that the health information that we have about you is incorrect or incomplete. Your request must be in writing to the Privacy Officer identified at the bottom of this notice, and it must explain reasons that support your request to amend your health information. We may deny your request under certain circumstances (e.g., it is not in writing, does not have support for the request, asks that we amend information that is accurate or complete, was not created by Advanced Dentistry, etc.). Right to Disclosure Accounting: You have the right to request a list of certain disclosures we have made of your health information. To request this accounting of disclosures, you must submit your request in writing to the Privacy Officer identified at the bottom of this notice. That list will not include disclosures for treatment, payment, health care operations, as otherwise authorized by you, and for certain other activities. 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. Contact us using the information listed at the end of this notice for more information about fees. Right to Request Restrictions: You have the right to request that we place additional restrictions on our use or disclosure of your health information for treatment, payment or healthcare operations. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency). In your request, you must tell us: (1) what information you want us to limit; (2) whether you want to limit our use, disclosure or both; and (3) to whom you want the limits to apply. We are not required to agree to your request. If we do agree, our agreement must be in writing signed by a person authorized to make such agreement on our behalf and we will endeavor to comply unless the information is needed to provide emergency treatment. Right to Alternative Communication: You have the right to request that we communicate with you about your health information in a certain way or at a certain location. You must make your request in writing to Advanced Dentistry at the address listed at the bottom of this notice. You must specify in your request the alternative means or location, and provide satisfactory explanation how you will handle alternative payment under the alternative means or location you request. We will endeavor to comply with all reasonable requests. Right to Copies of This Notice: 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. You may request a paper copy of our notice. Right to File A Complaint: You may contact Advanced Dentistry if you believe that we have violated your privacy rights, we made a decision about access to your health information incorrectly, our response to a request you made to amend or restrict the use or disclosure of your health information was incorrect, or we should communicate with you by alternative means or at alternative locations. 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 will not penalize you on the basis of filing a complaint. CONTACT INFORMATION If you want more information about our privacy practices or have questions or concerns, please contact us using the information listed below. Advanced Dentistry 11790 SW Barnes Road, Suite 260 Portland, OR 97225 Phone: 503-352-3224 Private Contract • • • We, Dr. David Halmos and Dr. Lauren Manning have not been excluded from Medicare under [1128] §§1128, [1156] 1156 or [1892] 1892 of the Social Security Act. I the Medicare beneficiary or my legal representative accept full responsibility for payment of charges for all services furnished by Advanced Dentistry. I the Medicare beneficiary or my legal representative understand that Medicare limits do not apply to what Advanced Dentistry may charge for items or services furnished. • I the Medicare beneficiary or my legal representative agree not to submit a claim to Medicare or to ask Advanced Dentistry to submit a claim to Medicare. • I the Medicare beneficiary or my legal representative understand that Medicare payment will not be made for any items or services furnished by Advanced Dentistry that would have otherwise been covered by Medicare if there was no private contract and a proper Medicare claim had been submitted. • I the Medicare beneficiary or my legal representative enter into this contract with the knowledge that I have the right to obtain Medicare-covered items and services from a physician and/or practitioner who has not opted-out of Medicare, and that the I am not compelled to enter into private contracts that apply to other Medicare-covered services furnished by other physicians or practitioners who have not opted-out. • The expected or known effective date and expected or known expiration date of the opt-out period is 5/20/2015 and 5/20/2017. • I the Medicare beneficiary or my legal representative understand that Medigap plans do not, and that other supplemental plans may elect not to, make payments for items and services not paid for by Medicare. • This contract cannot be entered into by myself, the Medicare beneficiary, or by my legal representative during a time when I, the Medicare beneficiary, require emergency care services or urgent care services. (However, a physician/practitioner may furnish emergency or urgent care services to a Medicare beneficiary in accordance with §3044.28 of the Medicare Carriers Manual) • I the Medicare beneficiary or my legal representative will receive or have received a copy (a photocopy is permissible) of this contract, before items or services are furnished to me under the terms of this contract. • We, Dr. David Halmos and Dr. Lauren Manning will retain the original contract (original signatures of both parties required) for the duration of the opt-out period. We, Dr. David Halmos and Dr. Lauren Manning will supply CMS with a copy of this contract upon request. • • We, Dr. David Halmos and Dr. Lauren Manning understand that the current private contract remains in effect for two years. If I again opt-out of Medicare, I will expediently complete a new contract for each Medicare beneficiary and will expediently submit the appropriate affidavit(s) to all local Medicare carriers. 7/8/2015 ________________________________________ _______________________ (Provider’s Signature: David R. Halmos) ________________________________________ (Provider’s Signature: Lauren B. Manning, DDS, DMSc) ________________________________________ (Patient’s Signature) ________________________________________ (Patient’s Name) ________________________________________ (Patient’s Legal Representative) ________________________________________ (Witness) (Date) 7/8/2015 _______________________ (Date) _______________________ (Date) _______________________ (Date) _______________________ (Date) ________________________ (Date) 11790 SW BARNES RD, STE 260 PORTLAND, OR 97225 (503) 352-3224 www.advanceddentistrypdx.com Directions to the Barnes Road Professional Campus Our office is located in the Barnes Road Professional Campus in southwest Portland on S.W. Barnes Road two blocks west of S.W. Cedar Hills Blvd. Please call our office for directions if you are unfamiliar with the area. Coming from Portland on Sunset Highway (26): Take Exit 68 (Cedar Hills Blvd) and turn right onto SW Cedar Hills Blvd. At the first light, turn left onto SW Barnes Rd. Go approximately 0.3 miles and just past SW 117th/Sunset Medical Clinic. Get into the left turn lane and turn into the Barnes Road Professional Campus. Our building (11790) is near the back of the campus in front of the parking structure. Coming from the South on Highway (217): At the North end of Hwy 217, take the Barnes Road exit and then stay in the left lane to head West on Barnes Road. Travel on Barnes Road approximately 0.3 miles past Cedar Hills Blvd and just past SW 117 (Sunset Medical Clinic). Get into the left turn lane and turn into the Barnes Road Professional Campus. Our building (11790) is near the front of the campus in front of the parking structure. th Coming from the West on Sunset Highway (26): Take Exit 68 (Cedar Hills Blvd). At the bottom of the ramp turn left on SW Cedar Hills Blvd. At the second light, turn left onto SW Barnes Road. Go approximately 0.3 miles and just past SW 117th/Sunset Medical Clinic. Get into the left turn lane and turn into the Barnes Road Professional Campus. Our building (11790) is near the back of the campus in front of the parking structure.