Patient Acknowledgements and Authorizations

Welcome! At Temple City Dental Care, we are committed to providing you with the best possible dental care and helping you achieve your optimum oral health. We feel that you deserve nothing less when it comes to your health. We use the best materials and techniques available to provide you quality dental care.

We believe that our relationship with you, as with all relationships, needs open and clear communication. We will try to communicate all your dental needs and estimate your financial information as soon as it becomes evident. We want you to be as informed as possible to help you in your decisions concerning your dental health.

We understand how valuable your time is, so we make every effort to remain on time. We do not double book our appointments. We feel that you deserve our complete and focused attention so that we may provide the best care possible. Your reserved time is exclusively yours.

Towards these goals, we would like to explain your financial and scheduling responsibilities with our practice.

Your Commitment (Patient Responsibilities)

We want you to be comfortable with our team. If you ever have any questions about your dental treatment, financial or insurance-related questions, or any concerns at all, we ask that you notify us as soon as possible. We will be glad to clarify any uncertainties that may arise.

Payment: Payment is due at the time services are rendered. Financial arrangements are discussed during the initial visit and a financial agreement is completed in advance of performing any treatment with our practice. We accept the following forms of payment: Cash, Check, and the following credit cards – American Express, Master Card, Discover, and Visa. We also offer third-party financing, which includes both interest-free programs and extended financing. Note: If you elect to apply for third-party financing, administered through our practice, we are required by law to provide you with a Credit for Dental Services Notice.

Dental Benefit Plans: Your dental benefit is a contract between you or your employer and the dental benefit plan. Benefits and payments received are based on the terms of the contract negotiated between you and your employer and the plan. We are happy to help our patients with dental benefit plans to understand and maximize their coverage.

We kindly ask that you realize we do NOT work for an insurance company. Rather, we work 100% for our patients. We feel that insurance can be a great benefit for many patients and want you to know we will do everything in our power to ensure you get every benefit allotted in your insurance contract. However, the treatment we recommend and the fees we charge WILL ALWAYS BE BASED ON YOUR INDIVIDUAL NEEDS, NOT YOUR INSURANCE COVERAGE.

Scheduling of Appointments: We reserve the doctor and the hygienist’s time on the schedule exclusively for each patient procedure and are diligent about being on time. Because of this courtesy, when a patient cancels an appointment, it affects the overall quality of service we are able to provide. We understand that circumstances may arise that require an appointment to be rescheduled; however, to maintain the utmost service and care, we do require a 48-hour notice to reschedule an appointment. With less than a 48-hour notice, a fee of $50.00, or deposit to reserve the appointment time again, may be required. To serve all our patients in a timely manner, we may need to reschedule an appointment if a patient is 15 minutes late or more arriving to our practice. To reschedule an appointment due to late arrival, a fee of $50 or deposit to reserve the next appointment, may be required.

Your scheduled appointment is reserved exclusively for you. We have a 48 hour cancellation policy in order to provide you with the personalized attention. We understand that circumstances may arise that require an appointment to be rescheduled. We are happy to change your reservation time if a 48 hour notice is given. If sufficient notice is not given, your account will be charged a $50 broken/missed appointment fee. We ask that you make every effort to keep your reserved time.

Patient Authorization
Patient Communications

Email: Except for appointment reminders, we use secure methods to electronically communicate with our patients. Unencrypted email is not a secure form of communication. There is some risk that any individually identifiable health information and other sensitive or confidential information that may be contained in such email may be misdirected, disclosed to or intercepted by unauthorized third parties. However, you may consent to receive unsecured email from us regarding your treatment. We will use the minimum amount of protected health information in any communication.

Please select one of the following three (3) options, initial, and provide your email address.

Mobile Phone

Patient Acknowledgements

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HIPAA Privacy Rule: Acknowledgement of Receipt of Notice of Privacy Practices §164.520(a)

I understand that as part of my health care, this facility originates and maintains health records describing my health history, symptoms, examination and test results, diagnosis, treatment, and any plans for future care or treatment. I hereby acknowledge that I have been provided with and understand that this facility’s Notice of Privacy Practices provides a complete description of the uses and disclosures of my health information. I understand that:

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Patient Information

Please allow 5 - 10 minutes to complete the form.

* = required

Home Address
Contact Information
Spouse Information
Emergency Contact

(Name of Relative of Friend, not living with you)

Insurance Information

Assignment of Insurance Benefits

I hereby authorize Temple City Dental Care to furnish information to insurance carriers concerning treatment and hereby assign to the doctors all payments for dental services rendered. This assignment will remain in effect until revoked by me in writing; a photocopy of this assignment is as valid as an original.
I understand that I am financially responsible for all charges whether or not paid by said Insurance/Dental Plan. I hereby authorize said assignee to release all information necessary to secure payment.
I authorize Jack Von Bulow, DDS, or the attending dentist to examine and provide medical/dental treatment. I assume full responsibility for any balance due. I authorize my insurance company to pay by check made out directly to Jack Von Bulow, DDS. I authorize the release of any medical or incidental information that may be necessary for either medical care or in processing applications for financial benefit. I understand it is my responsibility to know all rules and restrictions of my insurance policy, to know which hospital, emergency rooms, laboratories, x-ray departments, specialists, and specialist providers which are assigned to me according to my insurance policy rule. It is Jack Von Bulow, DDS's procedure to share Protected Health Information with labs, x-rays, consulting physicians, and hospitals. We will call the pharmacy of your choice regarding your prescriptions. We will only exchange minimum necessary Protected Health Information for each transaction.

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Medical History


An allergic reaction to :


Describe any current medical treatment, impending surgery, genetic/developmental delay, or other treatment that may possibly affect your dental treatment (i.e. Botox, Collagen Injections):

List all medications (over-the-counter and prescription), supplements, and/or vitamins taken within the last 2 years.


Dental History