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  • Patient Information

  • Contact Information

  • At which of the above numbers would we most likely be able to reach you:

  • Whom may we thank for referring you to our office?

  • Family Information

  • Person with whom we can leave an urgent message for you

  • Account Information

  • Dental History

  • Medical History

  • For the following questions, select yes or no. Your answers are for our records only and will be considered confidential. Please note that during your initial visit you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health.

  • NameStrength/AmountHow OftenReason 
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  • Do you have or have you had any of the following diseases or problems? (Select 'yes' or 'no' for each)

  • Are you allergic or have you had a reaction to any of the following? If yes, please describe the reaction (i.e. nausea, rash, shortness of breath, headache, etc.)

  • Please complete the following:

  • Women:

  • I certify that I have read and understand the above. I acknowledge that my questions, if any, about the inquiries above have been answered to my satisfaction. I will not hold my dentist, or any other member or his/her, responsible for any errors or omission that I may have in the completion of this form.

  • Additional Authorizations

  • Due to privacy rules, Dr. Timothy Kosinski is restricted in how we can communicate with you. Unless we receive authorization from you, we are prohibited from discussing your medical care or billing matters with your spouse, adult children, power of attorney or other individuals. Please indicate here your preferred method of contact, and list the individuals with whom we are permitted to discuss information.

  • I prefer to be notified about matters relating to my treatment and/or payment for services by (fill out all that apply):

  • I authorize Dr. Timothy Kosinski to discuss my treatment and/or billing matters with the following individuals:

  • A copy of this signature is as valid as the original.

  • Release Guidelines

  • Dear Valued Patient / Family of Dr. Timothy Kosinski:

    The United States government has passed a law that requires us to clearly identify guidelines for release of medical information. This law took effect on April 14, 2003. The purpose of this law is to safeguard medical information from sources not authorized to posses this information and at the same time to release appropriate information to other healthcare providers, insurance companies and other authorized agencies.

    You have the right to request restrictions on the use and disclosure of your health information. You also have the right to inspect and / or copy your health information. We may charge you a reasonable charge to cover copying, etc. It is our goal and requirement that we use your medical information with confidentiality and our best judgment in any communication with your family and others.

    An expanded document is available upon request, which covers these issues in greater detail. If you would like a copy of this document, please let our office staff know and we will be happy to provide it to you.

    Dr. Timothy Kosinski is in compliance with the Red Flag Rule, which became effective August of 2009. A copy of the policies and procedures is available upon request. If you would like a copy of the document, please let our office staff know and it will be provided to you.

    Sincerely,

    Dr. Timothy Kosinski

  • I have read the above and understand my rights under these new regulations.

  • Photo and Video Release Agreement

    I hereby grant permission to Dr. Kosinski and his staff to use my (or my child’s) likeness in a photo or video for dental publication, production of printed materials, and all other education and marketing materials including but not limited to our website, Facebook and other social media outlets.