PATIENT REGISTRATION AND HEALTH HISTORY FORM
· Print a copy of the Patient Registration/Health History Form – Adult Patients
NOTICE OF PRIVACY PRACTICES
Patients at Creighton University School of Dentistry have the right to:
receive considerate, respectful and confidential care.
receive and have access to current and complete information regarding their oral conditions.
an explanation of recommended care and alternate care as well as an explanation of the advantages, disadvantages, costs, expected outcomes, and time involved for each.
choose voluntarily to receive treatment or refuse treatment once given the information about the risks of either choice (informed consent).
the availability of emergency, incremental and/or total (comprehensive) treatment care.
receive timely, ongoing care until the agreed upon treatment is completed, realizing that treatment takes longer in a teaching environment due to educational and quality control measures.
receive care that meets the standard of care for the dental profession, including currently accepted infection control measures.
take a "time out" if care is too lengthy or too uncomfortable.
a patient advocate to discuss or mediate concerns related to their care or treatment at the School.
If you have any questions or comments, please call our patient advocate at 402-280-5049.
CONSENT TO TREAT
All treatment is provided by students under the supervision of licensed clinical teaching staff. Patients are accepted for comprehensive dental care, however because of the complex nature of some treatment, not all patients can be appropriately treated in a dental school setting.
The Dental School accepts patient applications from all people, regardless of sex, age, race, religion, color, ethnic origin, or disability status.
You will be assigned to a student who will be responsible for the management of your care. Some of your treatment may be performed by other students based upon the educational needs of the students.
More time is required to deliver care in a dental school setting than in a private dental office.
Student availability in the clinics is limited by other academic requirements. It is important to the student for you to keep appointments. Please notify your student one day in advance if you must cancel an appointment. Treatment may be discontinued for patients who fail two appointments without prior notification, who are constantly late for their appointments, or continue to excessively cancel appointments, who fail to practice acceptable oral hygiene, or who are uncooperative with students and staff.
Services are provided on a pay as you go basis unless other arrangements are made in advance. Insurance payments are accepted following approval of pre-treatment estimates. Those charges not covered by insurance remain the responsibility of the patient.
Clinical fees are subject to change.
All records, x-rays, photographs, etc. are the property of the school and may be used for teaching, clinical demonstration, or publication in scientific journals. Copies of records will be furnished upon written request. There will be a fee for duplication of records.
A parent or legal guardian must accompany children to each appointment and must stay in the reception room. The reason for this is that we may have questions about your child and only the parent or legal guardian may give us consent to proceed with treatment.
If your child has asthma and uses an inhaler, please remember to bring the inhaler. Without an inhaler for the safety of your child, we may not be able to treat your child that day.
The Patient Information form must be completed by the patient or legal guardian before receiving treatment.
You will be asked to provide a government issued photo identification (driver’s license, passport, retired or active duty military id) at the time of service. See Medical Identity Theft Policy below for more information.
If you have any questions or concerns about your treatment or student dentist, consult the Clinic Director at 402-280-5077.
MEDICAL IDENTITY THEFT POLICY
Patients will be asked to provide government issued photo identification (for example, driver's license, passport, retired or active duty military ID) at the time of service. If you do not have government issued photo identification, two forms of non-photo identification are required, one of which is from a government agency (for example, social security card, Medicaid card, or Medicare card plus current utility bill, current bank statement, current pay stub, work identification or school identification). If you do not have government-issued photo identification, the Dental School will take your photo after you have provided two forms of non-photo identification and include the photo in your dental health record. Once your photo is taken, you will not need to bring the two forms of non-photo identification to each appointment.
The Mission of the dental education program at Creighton relates to the Mission of the University.
The purpose of the School of Dentistry is to educate students who can demonstrate the attainment of competence and the progression toward proficiency in providing for the oral health needs of society. This education will be conducted in a culture and learning environment that reflects Ignatian humanism and a Catholic, Jesuit heritage. It is designed to be comprehensive in nature and to challenge students to reflect on transcendent values as well as instill caring, ethical, and moral components in their professional lives. This educational experience will enable students to manage with confidence all phases of comprehensive dental care and to communicate professionally in both oral and written forms. It will also prepare students to evaluate and implement new knowledge and to accept their responsibility of service to one’s community and profession.
The School of Dentistry has the responsibility of providing quality dental care in a comprehensive manner for those people who choose to become patients in the School’s clinics. The School also has the responsibility and obligation to foster and cultivate dental research.
Creighton University School of Dentistry is committed to excellence in education, patient care, service and research. It exists to develop dental professionals who will use the knowledge and technology of the 21st century in the Jesuit educational tradition characterized by compassion, leadership, professionalism, creativity, service, and social justice.