Patient Information

Thank you for choosing Breez Dental. For your convenience, we included below the form you'll need during your first visit, please fill out before you arrive for your appointment.
Adult New Patient Paperwork
Child New Patient Paperwork
  • New Patient
  • Insurance
  • Office policy
  • notice of privacy practices

Patient Information

Thank you for choosing Breez Dental. For your convenience, we included below the form you'll need during your first visit, please fill out before you arrive for your appointment.
  • Patient Information

  • Dental History

  • Dental Insurance

  • Date Format: MM slash DD slash YYYY
  • Medical History

  • By typing your name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature.
  • Signed on: 07/21/2019

Insurance Filing Policy

  • We will be more than happy to file and track your dental insurance claims on your behalf as a courtesy; however, the guarantor of the patient account is responsible for the cost of the dental treatment.

    The ultimate responsibility of knowing your plan lies between you, your employer, and your contracted insurance carrier. Due to the vast number of insurance carriers, varied plans and changing agreements, it would be impossible for our office to be expertly versed in all plans, at all times.

    Please be aware that we can’t guarantee your carrier’s payment. It is up to you to know your policy benefits and limitations. The total treatment cost provided by Breez Dental is an estimate based on the information we have on file for your specific insurance plan.

    If you have dual coverage dental insurance, this doesn’t always mean that you will receive dual payment. Some carriers have a non-duplication clause. If your company reimburses for treatment, the secondary company may not. Please be aware of your policies.

    If you change insurance carriers during treatment, you must notify our office immediately. This could change the original contract and adjustments may need to be made.

    I have read and understood the above-written insurance filing policy of Breez Dental. I understand that any monies not paid by my insurance carrier, for any reason, shall be the responsibility of the guarantor.


  • By typing your full name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature.
  • Signed on: 07/21/2019

Office Policy

  • Welcome to Breez Dental. In an effort to better serve you, we have listed our office policies below. If you have any questions, please feel free to ask one of our dental personnel.
  • 1. We only use composite (resin/tooth colored) or white fillings. We do not use mercury based amalgam or silver fillings.
  • 2. When scheduling your appointments, we reserve a special time just for you. Therefore, we appreciate and require a 24 hour notice for any cancellations. A $35.00 charge will be assessed for any missed or cancelled appointments within 24 hours of your scheduled visit.
  • 3. It is recommended that diagnostic digital x-rays be taken once a year. It is understood that without x-rays we are unable to do a full clinical exam, since we cannot see between the teeth or under the gums without them.
  • 4. Periodontal health is directly related to heart and overall systemic health. Our new comprehensive exams will include full periodontal charting with probings. If it has been over a year since your last dental cleaning, we will complete updated periodontal charting and it may be recommended that you have a deep cleaning done at your follow up visit. Failure to do so may lead to bone loss or the loss of teeth.
  • 5. We appreciate when you arrive on time for your appointment and realize that there may be traffic or extenuating circumstances which may cause you to run behind, so we allow a 15 minute leeway. However, if you are later than 15 minutes, we may require that you reschedule your appointment. It will be up to the discretion of Dr. Sebree and or the hygienist.
  • 6. If you will not be using dental benefits your payment for the appointment is due in full at the time of service. If you will be using your dental benefits, your estimated out of pocket is due at the time of service. Including, but not limited to, co-pays and deductibles.
  • 7. Our team at Breez Dental cares about you and your overall health. We will ask at each appointment you bring an updated list of current medications, and we will take your blood pressure at the beginning of every appointment.


  • We treat all of our patient’s as if they are family. Thank you for choosing us to service your dental needs. If there is anything we can do to make your visit with us more comfortable, please let us know.



  • Thank you!
    The staff at Breez Dental

  • By typing your full name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature.
  • Signed on: 07/21/2019

NOTICE OF PRIVACY PRACTICES

THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION

PLEASE REVIEW CAREFULLY THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice of Privacy Practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this notice while it is in effect. This notice took effect on January 1st, 2003, and will remain in effect until we replace it. We reserve the right to change our privacy practices and the terms of the notice at any time, provided such changes are permitted by applicable law.

We reserve the right to make the 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. You may request a copy of our notice at any time. For more information about our privacy practices, or for additional copies of these notices, please contact us using the information listed at the end of this notice.

Payment: We may use and disclose your health information to obtain payment for the services we provide you. Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.

Your Authorization: In addition to our use of our health history for treatment, payment or healthcare operations, you may give us written authorization to use your healthcare 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 was 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 the notice. We may disclose your health information to a family member, friend or other people to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so. 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 death. If you are present, then prior to the use of 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 healthcare. 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, x-rays, or other similar forms of health information.

Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.

Required by Law: We may use or disclose your health information when we are required to do so by law. 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 officials 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 inmate or patient under certain circumstances.

Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).


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 using the contact information listed at the end of this notice. 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 to the address at the end of this notice. If you request copies, we will charge you a fee for staff time to locate and copy your health information, and postage if you want the copies mailed to you. The same charge will be applied to alternate formats. If you prefer, we will 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 a full explanation of our fee structure.

Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in the 12-month period, we may charge you a reasonable, cost-based fee for responding to the additional requests.

Restrictions: 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 an emergency).

Alternative Communications: You have the right to request that we communicate with you about our 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 how payments will be handled under the alternative means or location you request.

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. If we deny your request we will respond in writing why we can not grant your request, and we will explain your options.

Electronic Notice: If you receive this notice on our web site or by electronic mail (e-mail), you are entitled to receive this notice in written form.


QUESTIONS AND COMPLAINTS
If you want more information about our privacy practices or has questions or concerns, please contact us. 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 alternate means or by alternate locations, you may complain to us by using the contact information listed at the end of this notice. You also may submit a written complaint to the US 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 support your right to the privacy of your information. We will not retaliate in any way if you choose to file a complaint with us or with the U.S. Department of Health and Human Services.
  • By typing your full name here, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature.
  • Signed on: 07/21/2019