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Welcome to our Office!

We are happy you have chosen our office for your dental services. We have been in Waconia for
more than 50 years. We have two offices, Waconia and Victoria. We have two doctors Laura B.
Menser, DDS and Jack M. Fiedler, DDS. Our Waconia office treatment hours are Monday
through Thursday, 8:00 a.m. to 5:00 p.m., and Friday 8:00 to 2:00 p.m. Victoria treatment
hours are Tuesday, Wednesday and Thursdays, 8:00 a.m. to 5:00 p.m.

We have attached forms for you to fill out at home. Please be sure to completely fill out these
forms and bring them with you to your first appointment. We ask that you have the forms
completed before your appointment so that the Doctor can see you at your scheduled
appointment time. The HIPPA Notice is for your information only and does not need to be
printed unless you want a copy for yourself. If you have a dental benefit plan, please be sure to
bring your dental card with you to your appointment. We file most claims electronically and we
are a provider for Delta Dental Premier, Cigna PPO, DeCare Dental and Health Partners Level 2.
Please check with your insurance prior to your appointment if you are concerned about
coverage. Most dental cards have a toll free telephone number listed on the card.

We request that parents accompany their children to our offices. If you cannot be present at
the appointment, you must call our office so that we can update the medical history and get
your permission regarding images, Fluoride and other treatment that may be necessary.

The doctors are on call for evening and weekend emergencies. Please call either office to get
emergency telephone numbers.

We look forward to getting to know you and your family.

Sincerely,

Dr. Laura B. Menser Dr. Jack M. Fiedler

Please be sure to bring your completed forms along to your appointment Thank you!
Medical History

Name ________________________________________ Date of Birth ______________

Although dental personnel primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems
that you may have, or medication that you may be taking, could have an important interrelationship with the dentistry you will receive.
Thank you for answering the following questions.

Are you under a physician's care now? Yes No


If yes, please explain:
Have you ever been hospitalized or had a major Yes No If yes, please explain:
operation? Yes No If yes, please explain:
Have you ever had a serious head or neck injury? Are Yes No If yes, please explain:
you taking any medications, pills, or drugs? Yes No
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or
any other medications containing bisphosphonates?
Yes No

Are you on a special diet? Yes No


Do you use tobacco? Yes No
Do you use controlled substances? Yes No

Women: Are you


Pregnant/Trying to get pregnant? Yes No Taking oral contraceptives? Yes No Nursing? Yes No

Are you allergic to any of the following?


Aspirin Penicillin Codeine Local Anesthetics Metal Latex Sulfa drugs
Acrylic
Other If yes, please explain:

Do you have, or have you had, any of the following?


AIDS/HIV Positive Yes No Cortisone Yes No Hemophilia Yes No Radiation Yes N
Alzheimer's Yes No Medicine Yes No Hepatitis A Yes No Treatments Recent Yes o
Disease Yes No Diabetes Yes No Hepatitis B or Yes No Weight Loss Renal Yes N
Anaphylaxis
Anemia Yes No Drug Addiction
Easily Winded Yes No C
Herpes Yes No Dialysis
Rheumatic Fever Yes o
No
Angina Yes No Emphysema Yes No High Blood Pressure Yes No Rheumatism Yes N
No
Arthritis/Gout Yes No Epilepsy or Seizures Yes No High Cholesterol Yes No Scarlet Fever Yes oNo
Artificial Heart Valve Yes No Excessive Bleeding Yes No Hives or Rash Yes No Shingles Yes No
Artificial Joint Yes No Excessive Thirst Yes No Hypoglycemia Yes No Sickle Cell Disease Yes No
Asthma Yes No Fainting Spells/Dizziness Yes No Irregular Heartbeat Yes No Sinus Trouble Yes No
Blood Disease Yes No Frequent Cough Yes No Kidney Problems Yes No Spina Bifida Yes No
Blood Transfusion Yes No Frequent Diarrhea Yes No Leukemia Yes No Stomach/Intestinal Disease Yes No
Breathing Problem Yes No Frequent Headaches Yes No Liver Disease Yes No Stroke Yes No
Bruise Easily Yes No Genital Herpes Yes No Low Blood Pressure Yes No Swelling of Limbs Yes No
Cancer Yes No Glaucoma Yes No Lung Disease Yes No Thyroid Disease Yes No
Chemotherapy Yes No Hay Fever Yes No Mitral Valve Prolapse Yes No Tonsillitis Yes No
Chest Pains Yes No Heart Attack/Failure Yes No Osteoporosis Yes No Tuberculosis Yes No

Cold Sores/Fever Blisters Yes No Heart Murmur Yes No Pain in Jaw Joints Yes No Tumors or Growths Yes No
Ulcers Yes No
Congenital Heart Yes No Heart Pacemaker Yes No Parathyroid Yes No
Venereal Ye No
Disorder Convulsions Yes No Heart Yes No Disease Yes No
Disease Yellow s No
Trouble/Disease Psychiatric Care Jaundice Ye
Have you ever had any serious illness not listed Yes
s
above?

If yes, please explain:


Comments:

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be
dangerous to my (or patient's) health. It is my responsibility to inform the dental office of any changes in medical status.

SIGNATURE OF PATIENT, PARENT, or GUARDIAN DATE


PATIENT REGISTRATION

ID: Chart ID:


First Name: Last Name: Middle Initial:
Patient Is: " Policy Holder Preferred Name:
" Responsible Party
Responsible Party (if someone other than the patient)
First Name: LastName:
Last Name: Middle Initial:
Address: Address 2:
City, State, Zip: Pager:
Home Phone: Work Phone: Ext: Cellular:
Birth Date: Soc Sec: Drivers Lic:

Responsible Party is also a Policy Holder for Patient Primary Insurance Policy Holder Secondary Insurance Policy Holder
Patient Information
Address: Address 2:
City: State / Zip: Pager:

Home Phone: ( ) Work Phone: Ext: Cellular: ( )

Sex: Male female Marital Status: Married Single Divorced Separated Widowed
Other
Birth Date: Age: Soc. Sec: Drivers Lic:

E-mail: _ _ _ _ " I would like to receive correspondences via e-mail.

Section 2 Section 3
Emergency
Additional Contact::
Comments:
Employment Status: Full Time Part Time Retired
::
Student Status: Full Time Part Time ::
Medicaid ID: Pref. Dentist: . Phone #:

Employer ID: Pref. Pharmacy:

Carrier ID: Pref. Hyg.:

Primary Insurance Information


Name of Insured: Relationship to Insured: Self Spouse Child Other

Insured Soc. Sec: Insured Birth Date:

Employer: Ins. Company

Address: Address:

Address 2: Address 2:

City,State,Zip: City,State,Zip:

Rem. Benefits: Rem. Deduct:


Secondary Insurance Information Relationship to Insured: Self Spouse Child Other
Name of Insured:

Insured Soc. Sec: Insured Birth Date:

Employer: Ins. Company

Address: Address:

Address 2: Address 2:

City,State,Zip: City,Sta

Rem. Benefits: Rem. Deduct:


Dental History

Name _______________________________________________________ Date ______________________

When was your childs last dentist appointment? ___________________________________________

Has your child complained about dental problems? __________________________________________

Has your child have any previous negative dental experiences? _______________________________

Does your child have any injuries to mouth/ teeth/ head? ____________________________________

Does your child have any oral habits thumb sucking, nail biting, mouth breathing, nursing bottle
habits, pacifier, etc., or does your child swim competitively?

Does your child have any unusual speech habits? ____________________________________________

Has your child have any lost teeth prematurely? ____________________________________________

Have any of your childs missing teeth been replaced? _______________________________________

Does your child wear or previously worn any Orthodontic appliances? _________________________

How often does your child brush his/her teeth? _____________________________________________

Do you assist your child with his/her tooth brushing? ____________ If so how often? ____________
Is dental floss part of your childs dental care? __________________ If so how often? ____________

Is fluoride taken in any form, rinse, city water, supplements?_ ________________________________

What is your childs attitude to dentistry? __________________________________________________

Based on our doctors recommendation, do you desire complete preventive care (exam, cleaning,
images and fluoride) for this child?
_______________________________________________________________________________________

Doctor notes:

Regarding Dentistry
Laura Menser, DDS & Jack Fiedler, DDS
regardingdentistry.com
7984 Victoria Drive, Victoria, MN 55386 | phone 952.443.2816 | fax 952.443.3694
st
133 West 1 Street, Waconia, MN 55387 | phone 952.442.2816 | fax 952.442.2821
CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION
Purpose of Consent: By signing this form, you will consent to our use and disclosures of your
protected health information to carry out treatment, payment activities, and healthcare
operations.

Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices
before you decide whether to sign this Consent. Our Notice provides a description of our
treatment, payment activities, and healthcare operations, of the uses and disclosures we may
make of your protected health information, and of other important matters about your protected
health information. A copy of our Notice accompanies this Consent. We encourage you to read
it carefully and completely before signing this Consent. We reserve the right to change our
privacy practices as described in our Notice of Privacy Practices. If we change our privacy
practices, we will issue a revised Notice of Privacy Practices, which will contain the changes.
Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practice, including any revisions of our Notice, at
any time by contacting: Regarding Dentistry - Business Assistant, 952-442-2816 or via email at
cindy@dmadentistry.com

Right to Revoke: You have the right to revoke the Consent at any time by giving us written
notice of your revocation submitted to the contact person listed above. Please understand that
revocation of this consent will not affect any action we took in reliance on this Consent before
we received your revocations, and that we may decline to treat you or to continue treating you if
you revoke this Consent.

I, _______________________________ have had full opportunity to read and consider the contents
of the Consent form and your Notice of Privacy Practices. I understand that, by signing this
Consent form, I am giving my consent for your use and disclosure of my protected health
information to carry out treatment, payment activities and health care operators.

A. Family and Friends. It is the policy of Regarding Dentistry not to release confidential
information regarding your treatment to family members or friends, except for, a parent/legal
guardian, or other persons authorized by the patient. If you anticipate that you will need or want
your medical information provided to a family member, friend, caretakers/babysitters, please
indicate that below, so that we may best serve you.

Regarding Dentistry
Laura Menser, DDS & Jack Fiedler, DDS
regardingdentistry.com
7984 Victoria Drive, Victoria, MN 55386 | phone 952.443.2816 | fax 952.443.3694
st
133 West 1 Street, Waconia, MN 55387 | phone 952.442.2816 | fax 952.442.2821
Please print the name of the individual you would like to have access to your
account and circle yes or no. If you do not want your medical information
provided to a family member, please circle the NO response.

INFORMATION HEALTH CARE FINANCIAL

SPOUSE __________________________________ YES/NO YES/NO

PARENT ___________________________________ YES/NO YES/NO

OTHER ___________________________________ YES/NO YES/NO

PRINT YOUR NAME:

_____________________________________________________________________________

SIGNATURE:

_____________________________________________ DATE:_________________________

*If you choose to not designate a spouse/parent/other, we will not give out
information regarding appointments, your account information or any information
pertaining to your dental care.

Regarding Dentistry
Laura Menser, DDS & Jack Fiedler, DDS
regardingdentistry.com
7984 Victoria Drive, Victoria, MN 55386 | phone 952.443.2816 | fax 952.443.3694
st
133 West 1 Street, Waconia, MN 55387 | phone 952.442.2816 | fax 952.442.2821
Insurance/Insurance Claims

Every insurance plan is different. It is your responsibility to know how your policy will pay for
services. If you have questions after a claim has been filed and paid, please check with your
insurance company prior to contacting our office if you disagree about their payment of
services.

You are ultimately responsible for payment of services provided, whether you have insurance or
not. You understand that all account balances that are over 60 days old will be accessed a 1.5%
finance charge per month (18% APR) and that you are responsible for payment of any finance
charges that are accrued. Estimated patient portion of dental fees are due at time of service.

Regarding Dentistry will submit insurance claims on your behalf as a courtesy to you. Without a
signature, we are unable to file insurance claims for you and your family.

You agree to be responsible for all charges for dental services and materials not paid by your
dental benefit plan, unless the treating dentist or dental practice has a contractual agreement
with your plan prohibiting all or a portion of such charges.

Cancelled/Failed Appointments

We have experienced a significant increase in "failed" appointments in which we did not receive
any notice or insufficient notice. Without this notice period, we are unable to fill the
appointment with another waiting family/patient. We know things come up in your schedule and
you may need to change your appointment. We need 48 hours notice for changes to
appointments. We will be happy to reschedule your appointment. Please be advised that you
may incur a self-pay $100.00 charge if we do not receive notice or if you fail more than one
appointment. Thank you for helping us to remain accessible to you and others!

To the extent permitted under applicable law, I authorize release of information relating to the
dental services to the insurance benefit plan.
I hereby authorize payment of the dental benefits otherwise payable to me directly to Regarding
Dentistry.

I understand that I am ultimately responsible for payment of services provided, whether I have
insurance or not.

I am aware that failed appointments (less than 48 hour notice) may cost me $100.00 per failed
appointment.

Signature ________________________________________________________ Date __________________


(Patient or parent/legal guardian if patient under age 18)
Regarding Dentistry
Laura Menser, DDS & Jack Fiedler, DDS
regardingdentistry.com
7984 Victoria Drive, Victoria, MN 55386 | phone 952.443.2816 | fax 952.443.3694
st
133 West 1 Street, Waconia, MN 55387 | phone 952.442.2816 | fax 952.442.2821
Transfer Dental Records Request

DATE: ___________________________

I am requesting my records to be sent to Regarding Dentistry. Please provide any current


X-rays or images, perio charting, incomplete treatment, and dates of last prophy and exam.

Patient Name: ____________________________________________ Date of Birth ___________________


Patient Name: ____________________________________________ Date of Birth ___________________
Patient Name: ____________________________________________ Date of Birth ___________________

Patient Signature _________________________________________________________________________

Parent Signature (if patient is under 18 years of age) ________________________________________

Please forward by mail to Regarding Dentistry - 133 W. First Street, Waconia, MN 55387
or electronically via email to waconia@dmadentistry.com if you have any questions, please call
Regarding Dentistry at 952.442.2816

Previous Dentist Contact Information:

Dentist Name ____________________________________________________________________________

Address _________________________________________________________________________________

City _____________________________________ State _______________ Zip Code __________________

Regarding Dentistry
Laura Menser, DDS & Jack Fiedler, DDS
regardingdentistry.com
7984 Victoria Drive, Victoria, MN 55386 | phone 952.443.2816 | fax 952.443.3694
st
133 West 1 Street, Waconia, MN 55387 | phone 952.442.2816 | fax 952.442.2821