Welcome To Dr. Todd J. Krempel DDS Dental Clinic!

A little bit of time now will save you a lot later.

To help us save time and meet all of your Dental Health needs, please fill out this online form completely and submit it.

Your progress will still be sent to the office, however once submitted, edits cannot be made until your visit.

If you have any questions or need assistance, please contact our Practice Manager and we will be happy to help.

Find out what to expect on your first visit here.

NOTE: Your Information submitted online is protected by SSL Encryption | We are HIPPA Compliant.


print patient forms

If you prefer to print your patient forms, you can download them below.


NEW PATIENT FORM
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HIPAA Compliance Patient Consent Form



Our Notice of Privacy Practices provides information about how we may use or disclose protected health information.

This notice contains a patient’s rights section describing your rights under the law. You ascertain that by your signature that you have reviewed our notice before signing this consent.

The terms of the notice may change, if so, you will be notified at your next visit to update your signature/date.

You have the right to restrict how your protected health information is used and disclosed for treatment, payment or healthcare operations. We are not required to agree with this restriction, but if we do, we shall honor this agreement. The HIPAA (Health Insurance Portability and Accountability Act of 1996) law allows for the use of the information for treatment, payment, or healthcare operations.

By signing this form, you consent to our use and disclosure of your protected healthcare information and potentially anonymous usage in a publication. You have the right to revoke this consent in writing, signed by you. However, such a revocation will not be retroactive.

By submitting this form, I understand that:

. Protected health information may be disclosed or used for treatment, payment, or healthcare operations.

. The practice reserves the right to change the privacy policy as allowed by law.

. The practice has the right to restrict the use of the information but the practice does not have to agree to those restrictions.

. The patient has the right to revoke this consent in writing at any time and all full disclosures will then cease.

. The practice may condition receipt of treatment upon execution of this consent.

MEMBER NAME(S) comma separated
Your Name Confirms Your Acceptance Of This Policy

New Patient Information Form | Patient Information (Confidential)

First Name
Last Name
Today's Date
###-##-####
Birthdate
Home Phone Number
Mobile Phone Number
Address
Patient’s or Parent’s Employer
Work Phone
Business Address
Spouse or Parent’s Name
Emergency Contact
Emergency Contact Phone Number

Responsible Party

Name of Person Responsible on Account
Relationship to patient
###-###-####
Birthdate
Employer
Work Phone
###-##-####

Primary Insurance Information

Name of Insured
Relationship to Patient
Birthdate
###-##-####
Name of Employer
Union or Local #
###-###-####
Insurance Company
Group #
Policy/ID #

Secondary Insurance Information

Name of Insured
Relationship to Patient
Birthdate
###-##-####
Name of Employer
Union or Local #
###-###-####
Insurance Company
Group #
Policy/ID #

Dental History

Reason for Visit
Former Dentist's First Name
Former Dentist's Last Name
mm/dd/yy

Check if you have had problems with any of the following:

How often do you Floss?
How often do you Brush?

Patient Medical History

Physician's Name
###-###-####
mm/dd/yy
2. Have you ever been hospitalized for any Surgical operation or serious illness within the last 5 years?
If yes, please explain:
3. Are you taking any medication including Non-prescription medicine?
If yes, What medication are you taking?:
4. Are you currently taking, or have you ever taken osteoporosis medication in the past?
If yes, how long? Which Ones?
5. Do you use tobacco?
6. Do you use controlled substances or Recreational drugs?
9. Check if you have or have had any of the following:

Authorization and Release

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis and the records of any treatment or examination rendered to me or my child during the period of such Dental care to third party payers and/or health practitioners. I agree to be responsible for payment of all service rendered on my behalf of my dependents.

Your Name Confirms Your Acceptance Of This Policy
mm/dd/yy

    
     
   

Dr. Todd J. Krempel DDS accepts the following methods of payment:

Insurance, Visa, Mastercard, Discover, Cash, and Personal Checks.

We pride ourselves on serving the Las Vegas community with the best service possible. Therefore, Dr. Krempel is open to finding the best financial plan for you, and will customize a personal payment plan that is within your own personal budget.