BlissDental Your Kendall General Dentist

(305) 274-6500

  • Dental Services
    • General
      • Cleanings
      • Dental Checkup
      • Emergency Dentist
      • Laser Dentistry
      • Pediatric Dental
      • Sedation Dentist
      • Full Mouth Reconstruction
      • Tooth Extraction
    • Restorative
      • All-on-4 Dental Implants
      • Dental Crowns and Bridges
      • Dental Implants
      • Dental Restorations
      • Full & Partial Dentures
      • Tooth Fillings
    • Cosmetic
      • Dental Veneers
      • Invisalign® Dentist
      • Smile Makeover
      • Zoom Teeth Whitening
    • Other
      • Botox
      • Juvéderm
  • About Us
    • Patient Form
    • Testimonials
    • Specials
    • Our Team
  • Gallery
    • Photo Gallery
    • Video Gallery
  • Pay Here
  • Contact Us
BlissDental Your Kendall General Dentist
  • Dental Services
    • General
      • Cleanings
      • Dental Checkup
      • Emergency Dentist
      • Laser Dentistry
      • Pediatric Dental
      • Sedation Dentist
      • Full Mouth Reconstruction
      • Tooth Extraction
    • Restorative
      • All-on-4 Dental Implants
      • Dental Crowns and Bridges
      • Dental Implants
      • Dental Restorations
      • Full & Partial Dentures
      • Tooth Fillings
    • Cosmetic
      • Dental Veneers
      • Invisalign® Dentist
      • Smile Makeover
      • Zoom Teeth Whitening
    • Other
      • Botox
      • Juvéderm
  • About Us
    • Patient Form
    • Testimonials
    • Specials
    • Our Team
  • Gallery
    • Photo Gallery
    • Video Gallery
  • Pay Here
  • Contact Us
(305) 274-6500
Contact Us

Dental appointments

"*" indicates required fields

1Patient Registration
2Covid 19 Questions
3Dental History Information
4HIPAA Compliance Patient Consent
5Payment Arragement

Patient Registration

MM slash DD slash YYYY
Gender
Address

Patient Health History

Do you have a history of:
A.I.D.S/HIV Positive
Alcoholism
Allergies
Anemia
Arthritis
Asthma
Blood Disease
Bone Disease
Cancer
Chemical Dependency
Chest Pain
Circulatory Problems
Convulsions/Seizures
Diabetes
Excessive Bleeding
Epilepsy
Glaucoma
Hay fever
Header injuries
Hearing Impaired
Heart Disease
Heart Valve, Murmur
Hepatitis/Liver Disease
Hepatitis Carrier
High Blood Pressure
Hip or Joint replacement
HPV
Jaundice
Kidney Disease
Kidney Dialysis
Latex Sensitivity
Lupus
Low Blood Pressure
Malignancies
Mitral Valve Prolapse
Neck & Back Problems
Nervous Problems/Disorders
Pacemaker
Prosthetic Joints
Psychiatric Care
Radiation Treatment
Respiratory Problems/Disorders
Rheumatic Fever
Rheumatism
Scarlet Fever
Seizures/Fainting spells
Sinus Problems
Stomach Ulcers
Stroke
Thyroid Disease
Tuberculosis
Tumors or growths
Ulcers
Venereal Disease

Medical Questions

Do you have any disease/problem you think we should know about?
Are you allergic to any medications?
Are you in good health?
MM slash DD slash YYYY
Have you ever been hospitalized?
Have you had a transplant operation that has depreseed your immune system?
Do you smoke or chew tobacco?
Have you had Heart Surgery?
Are you now under the care of an MD?
Are you taking or have you ever taken bisphosphonates? (Fosamax or Actonel for osteoporosis, chemotherapy, etc)

Covid 19 Questions

MM slash DD slash YYYY
As a safety measure to our staff and other patients, we kindly ask that you answer the following questions:
Como medida de seguridad para nuestro personal y otros pacientes, le rogamos que responda las siguientes preguntas:

 

Gracias por su cooperacion.

 

Dental History Information

For woman only
Are you taking birth control pills?
Are you nursing/breastfeeding?
Are you pregnant?
MM slash DD slash YYYY
Is there a possibility of pregnancy?

NOTE: Antibiotics (such as penicillin) may alter the effect of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.


Do you snore?
Do you have problems with bad breath?
Have you ever had an allergic reactions to a crown, metal filling or dental appliance?
Have you ever had an oral cancer screening?
Have you ever used an electric toothbrush?
 
On a scale from 1 to 10, with 10 being the highest
Are your teeth sensitive to hot, cold or pressure?
Do your gums bleed when you brush?
Have you ever had complications from an extraction?
Are you prone to frequent headaches?
Do you grind or clench your teeth?
Do you have sores, blisters or swelling on your gums lips or cheeks?
Have you ever had orthodontic treatment?
Have you ever had a popping or clicking near your ear when you chew?
Have you or a family member ever been treated for periodontal disease?
If you could change something about your smile what would it be:

I certify that I have read and understand the questions, above. I acknowledge that my questions have been answered to my satisfaction. I will not hold my dentist or any other members of his/her staff responsible for any errors that I have made in the completion of this form.

Adult/Guardian: I hereby consent to the treatment indicated on my examination form, including the use of any anesthetics, sedatives, or x-rays, as may be deemed necessary by the doctor.

MM slash DD slash YYYY

HIPAA Compliance Patient Consent

Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

The notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By signing this form, I understand that:

• Protected health information may be disclosed or used for treatment, payment, or healthcare operations.
• The practice reserves the right to change the privacy policy as allowed by law.
• The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.
• The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.
• The practice may condition receipt of treatment upon execution of this consent.

May we phone, email, or send a text to you to confirm appointments?
May we leave a message on your answering machine at home or on your cell phone?
May we discuss your medical condition with any member of your family?

MM slash DD slash YYYY
MM slash DD slash YYYY

Payment Arragement

Payment Agreement

I agree that I am responsible for all services rendered to the Patient and that payment is due and payable to the Practice at the time services are rendered and that health, dental and accident insurance policies are an arrangement between my insurance carrier and me. I agree to pay all deductibles and co-pays at the time of service (if I have dual insurance coverage, my co-pay or deductible will be based on the primary coverage). I understand that while the Practice will file claims with my insurance company on my behalf, I remain responsible to the Practice for what is not paid by my insurance company. I also understand that if the Practice cannot verify insurance benefits eligibility for me prior to treatment that I will pay in full for the services at the time they are rendered. I understand that the Practice may charge: 1) a late fee if payment on my account is not received by the due date; 2) an amount equal to $35.00, but not to exceed the maximum amount permitted by law for each returned check, and 3) a fee of $50.00 for each appointment that is missed/canceled without at least 24 hours advance notice. I agree to the extent permitted by law, that if my account balance is referred to any agency or attorney(s) for collection purposes, to pay reasonable attorney's fees and any expenses or costs relating to the collection proceeding, including court costs. I understand that if treatment or care is suspended at any time by the patient, all fees for professional services rendered will be immediately due and payable. I authorize payment directly to the Practice.

Insurance Information

MM slash DD slash YYYY

I acknowledge having received a copy of the Practice's Notice of Privacy Practices. I agree that a photocopy of this authorization is as valid as the original.

MM slash DD slash YYYY

(To be signed even if Patient is also the Responsible Party)

This field is for validation purposes and should be left unchanged.

BlissDental Your Kendall General Dentist

© 2023 Bliss Dental. All rights reserved.

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5 stars from 275 reviews

Contact Info

  • 8501 SW 124th Ave Ste 104
    Kendall, FL 33183
  • Phone: (305) 274-6500
Pay Here

Hours of Operation

Monday: 9:00AM to 5:00PM
Tuesday: 9:00AM to 7:00PM
Wednesday: 9:00AM to 5:00PM
Thursday: 9:00AM to 5:00PM
Friday: 9:00AM to 5:00PM
Saturday: 8:00AM to 2:00PM *
Sunday: Closed

*first Saturday of the month