top of page

PATIENT FORM

Please fill in the following information. Your answers are for our records only and will be kept strictly confidential subject to applicable laws. Please note that you will be asked some questions concerning your health. This information is vital to allow us to provide you the best care possible.

General Information

Date of Birth
Gender

Contact Information

Emergency Information

Dental Information

For the following questions, please circle which answer applies. If you do not know the answer, circle the “?”. Your answers are for our records only and will be kept confidential in accordance with the applicable laws. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.

Do your gums bleed when you brush or floss?
Yes
No
?
Are your teeth sensitive to cold, hot, sweets, or pressure?
Yes
No
?
Does food or floss catch between your teeth?
Yes
No
?
Have you had any periodontal (gum) treatment?
Yes
No
?
Have you ever had orthodontic (braces) treatment?
Yes
No
?
Have you had any problems associated with previous dental treatment?
Yes
No
?
Is your home water supply fluoridated?
Yes
No
?
Do you drink bottled or filtered water?
Yes
No
?
Are you currently experiencing dental pain or discomfort?
Yes
No
?
Do you have earaches or neck pains
Yes
No
?
Do you have any clicking, popping, or discomfort in your jaw?
Yes
No
?
Do you grind your teeth?
Yes
No
?
Do you have any sores or ulcers in your mouth?
Yes
No
?
Do you wear partial dentures?
Yes
No
?
Do you wear complete dentures?
Yes
No
?
Have you ever had a serious injury to your head, neck, or mouth?
Yes
No
?

Medical Information

Are you in good health?
Yes
No
?
Has there been any change in your general health with the past year?
Yes
No
?
Are you currently under the care of a physician for a specific condition?
Yes
No
?
Do you wear contact lenses?
Yes
No
?
Have you had any complications or difficulties with your prosthetic joint?
Yes
No
?
Has a physician or a previous dentist ever recommended that you take antibiotics prior to your dental treatment?
Yes
No
?
Have you ever reacted adversely to any medications or injections?
Yes
No
?
Do you drink alcoholic beverages?
Yes
No
?
Do you use tobacco (smoking, snuff, chew, bidis, vaping)?
Yes
No
?

For female patients

Are you pregnant?
Yes
No
?
Are you nursing?
Yes
No
?
Are you taking birth control pills?
Yes
No
?

Sleep screen questionaire - Epworth Sleeping Scale

In contrast to just feeling tired, how likely are you to doze off or fall asleep in the following situations?

Use the following scale to choose the most appropriate number for each situation:


0 - Would never doze off                              

1 - Slight chance of dozing

2 - Moderate chance of dozing     

3 - High chance of dozing


A score of 8 or greater indicates the possibility of sleep disordered breathing.


SITUATION

Sitting and reading
Watching Television
Sitting inactive in a public place (i.e. theater)
As a car passenger for an hour without a break
Lying down to rest in the afternoon
Sitting and talking to someone
Sitting quietly after lunch without alcohol
In a car, while stopping for a few minutes in traffic

Smile Assessment Questionnaire

Are your teeth straight?
Yes
No
?
Have you ever had orthodontic treatment?
Yes
No
?
Are you satisfied with the color of your teeth?
Yes
No
?
Are you satisfied with the shape of your teeth?
Yes
No
?
Are there any spaces between your teeth that you dislike?
Yes
No
?
Are you satisfied with the way your teeth come together (your bite)?
Yes
No
?
Do you have old fillings or dental work that makes you feel less confident about your smile or appearance?
Yes
No
?

Fotona Laser Questionnaire - Would You Be Interested in the Following Services?

NightLase® - A Non-Surgical Snoring Treatment for Better Quality Sleep
Yes
No
?
SmoothLase™ - Intra-Oral, Anti-Aging Facial Treatment
Yes
No
?
LipLase™ - All Natural Laser Lip Plumping Treatment
Yes
No
?
ComfortLase™ - The Ideal Solution for Wound Healing and Pain Reduction
Yes
No
?

At Dr. Boisvert's office, we are proud to be part of a dedicated team focused on providing the highest quality and most comprehensive dental care available today. Our goal is to make exceptional care as cost-effective as possible. Payment for services is due at the time of treatment, as we do not bill for dental procedures.

To make paying for your care easier, we offer the following payment options:


  • Cash (including money orders and personal checks)

  • Major credit cards: MasterCard, Visa, American Express, Discover

  • CareCredit: An external financing option offering credit lines to cover healthcare costs for you and your family

  • RepeatMD App Financing


Dental Insurance:

If you have dental insurance, please provide your information to our office staff. As a courtesy, we will bill your insurance on your behalf, and you will receive any reimbursement directly at home. However, payment is expected at the time of service.

Keep in mind that some insurance companies pay fixed allowances for specific procedures, while others pay a percentage of the charges. It is your responsibility to understand your benefits and cover any deductibles, coinsurance, or remaining balance not paid by your insurance.

We can contact your insurance provider before your appointment to obtain a current benefits summary and will inform you of the details provided by your insurer. Please note that benefit information is valid only as long as there are no changes to your employment status or the terms of your insurance plan. You are responsible for notifying us of any changes to your coverage.


Financial Responsibility:

I understand that I am financially responsible for all charges, regardless of insurance payment (if applicable). I authorize the release of necessary information to secure payment for services, including the disclosure of relevant dental records.

If payment is not received in full, I agree to a 1.5% interest fee on overdue balances. Accounts that remain unpaid for more than 3 months will be referred to collections, and I will be responsible for all collection costs, including reasonable attorney's fees and interest at a rate of 18% per annum.


Missed Appointment / Cancellation Policy:

At Biosmile Dentistry we are committed to providing all our patients with exceptional care. When a patient cancels without giving us enough notice, it prevents another patient from being seen. Please email us at hello@biosmiledentistry.com or call us at (310) 310-4696 48 hours prior to your scheduled appointment to notify us of any changes or cancellations. To cancel a Monday appointment, please call our office by 2:00 p.m. on Friday. If prior notification is not given, you will be charged $125 per hour for the missed appointment. If a patient is more than 15 minutes late, an additional fee of $25 per hour will be charged for the late appointment.


Notice of Privacy Practices

This notice describes how your health information 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

Federal and state laws require us to maintain the privacy of your health information. We are also required to provide this notice about our office’s privacy practices, our legal duties and your rights regarding your health information. We are required to follow the practices that are outlined in this notice while it is in effect. This notice takes effect April 14,2003 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 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. For more information about our privacy practices or additional copies of this notice, please contact us (contact information below).


USES AND DISCLOSURES OF HEALTH INFORMATION

We use and disclose health information about you for treatment, payment, and health care operations. For example:

 

Treatment: We disclose medical information to our employees and others who are involved in providing the care you need. We may use or disclose your health information to another dentist or other health care providers providing treatment that we do not provide. We may also share your health information with a pharmacist in order to provide you with a prescription or with a laboratory that performs tests or fabricates dental prostheses or orthodontic appliances.

 

Payment: We may use and disclose your health information to obtain payment for services we provide to you, unless you request that we restrict such disclosure to your health plan when you have paid out-of-pocket and in full for services rendered.

 

Health Care Operations: We may use and disclose your health information in connection with our health care operations. Health care operations include, but are not limited to, quality assessment and improvement activities, reviewing the competence or qualifications of health care professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing, or credentialing activities.

 

Your Authorization: In addition to our use of your health information for treatment, payment, or health care operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it is in effect. Unless you give us a written authorization, 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. You have the right to request restrictions on disclosure to family members, other relatives, close personal friends, or any other person identified by you.

 

Unsecured Email: We will not send you unsecured emails pertaining to your health information without your prior authorization. If you do authorize communications via unsecured email, you have the right to revoke the authorization at any time.


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 your 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 health care. 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 or X-rays

Marketing Health-Related Services: We may contact you about products or services related to your treatment, case management or care coordination or to propose other treatments or health-related benefits and services in which you may be interested. We may also encourage you to purchase a product or service when you visit our office. If you are currently an enrollee of a dental plan, we may receive payment for communications to you in relation to our provision, coordination, or management of your dental care, including our coordination or management of your health care with a third party, our consultation with other health care providers relating to your care or if we refer you for health care. We will not otherwise use or disclose your health information for marketing purposes without your written authorization. We will disclose whether we receive payments for marketing activity you have authorized.

 

Change of Ownership: If this dental practice is sold or merged with another practice or organization, your health records will become the property of the new owner. However, you may request that copies of your health information be transferred to another dental practice.

 

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

 

Public Health: We may and are sometimes legally obligated to, disclose your health information to public health agencies for purposes related to preventing or controlling disease, injury, or disability; reporting abuse or neglect; reporting domestic violence; reporting to the Food and Drug Administration problems with products and reactions to medications; and reporting disease or infection exposure. Upon reporting suspected elder or dependent adult abuse or domestic violence, we will promptly inform you or your personal representative unless we believe the notification would place you at risk of harm or would require informing a personal representative, we believe is responsible for the abuse or harm.

 

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 official’s health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institutions or law enforcement officials having lawful custody of protected health information of inmates or patients under certain circumstances.

 

Appointment Reminders: We may contact you to provide you with appointment reminders via voicemail, postcards, or letters. We may also leave a message with the person answering the phone if you are not available.

 

Sign-In Sheet and Announcement: Upon arriving at our office, we may use and disclose medical information about you by asking that you sign an intake sheet at our front desk. We may also announce your name when we are ready to see you.

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 contacting our office. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter. If you request copies, we will charge you $0.75 for each page $20.00 per hour staff time to locate and copy your health information, and postage if you want the copies mailed to you. If you request an alternate 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 for a full explanation of our fee structure.

 

Disclosure Accounting: You have a right to receive a list of instances in which we disclosed your health information for purposes other than treatment, payment, health care operations and certain other activities for the last six years. 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 emergency). In the event you pay out-of-pocket and in full for services rendered, you may request that we not share your health information with your health plan. We must agree to this request.


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 of how payments will be handled under the alternative means or location you request.

 

Breach Notification: In the event your unsecured protected health information is breached, we will notify you as required by law. In some situations, you may be notified by our business associates.

 

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 Website or by electronic mail (e-mail), you are entitled to receive this notice in written form.


QUESTIONS AND COMPLAINTS

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 also 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 against you for filing a complaint with us or with the U.S. Department of Health and Human Services.

 

If you want more information about our privacy practices or have questions or concerns, please contact us at:

 

Telephone: (310) 310-4696

Fax: (310) 575 2982

Email: hello@biosmiledentistry.com

Address: 2428 Santa Monica Blvd Suite 303 Santa Monica, CA 90404

bottom of page