Patient Forms

Thank you for choosing Channo DDS. For your convenience, this section includes forms that you’ll need for your first visit and will consist of what to expect during your first appointment. If you may have any questions regarding your upcoming visit, please contact the Channo DDS office in Rochester, MI. We’re here to help you receive the best dental care, and we welcome you to our practice!

Please complete the following information, and be sure to bring these forms to your first appointment. Below, we’ll provide a comprehensive explanation for our forms, including the HIPPA acknowledgment section, the medical history questionnaire, and our practice policies regarding Dr. Channo, his staff, and our dental services.

Patient Registration

Under the patient forms, you’ll find patient registration as the first section of information to fill out, which will include patient contact information and/or the responsible party’s contact information. The contact information should include:

• Name
  
• Address
  
• Home/Work Phone Number
  
• Employment Status
  
• Insurance Policy Information

Medical History

The medical history section provides a basic questionnaire about you or the patient’s medical history and expands on providing space for the patient to provide relevant information. Questions regarding serious injuries, prescribed medications, special diets, and allergic reactions are part of the procedural listing. Dr. Channo, while providing your first appointment, will take your medical history into account when providing an assessment of your oral health. A comment section below the questionnaire can be found to place any additional information that Dr. Channo should know before proceeding. Lastly, a signature will be required to validate the information given on the sheet.

HIPPA Acknowledgment

The HIPPA Acknowledgment section recognizes that you have received these forms and have protective rights regarding your health information. HIPPA forms are a standardized legal form required by all medical practices to establish national standards for protecting patient’s medical records. For more information about the HIPPA policy, you can read more about it through the Health Information Policy website.

Within the acknowledgment section, your signature acknowledges the Notice of Privacy Practices, a notice explaining the individual’s rights to respect their personal health information and the privacy practices of health plans and their healthcare providers. Through this signature, Dr. Channo can provide dental services through active engagement with your medical records.

Dental History

The dental history form provides Dr. Channo with additional information regarding your appointment and must be filled out before or during each appointment to receive dental care. Throughout the document, patients receiving care at Channo DDS will fill out necessary information regarding their dental habits, any current dental problems, the patient’s last dental checkup, and a recent date of dental x-rays. Below, our appointment policy can be found outlining our appointment scheduling process, notification for canceling or rescheduling appointments, and any additional fees that may be present during or after the appointment. The patient’s signature acknowledges our appointment policies and the accuracy of the information provided about the patient’s most recent dental history.