Patient Forms

Comprehensive Consent Form

Patient intake, consent, financial agreement, and authorized representative form. Please complete this before your first visit so your appointment time stays focused on your care.

This form covers the scope of preventive dental hygiene services, teledentistry, radiographs, Silver Diamine Fluoride, privacy practices, collaborative care, communication preferences, and the payment agreement. Sections that do not apply to you may be left blank.

Prefer to review it on paper first? Use Print a Copy at the bottom of the form, or reach us through the contact page and we will send one over.

1. Patient Information

2. Assisted Living / Facility Information

3. Authorized Representative / POA / Guardian

Complete this section if a healthcare power of attorney, legal guardian, conservator, or other authorized representative is involved in decisions or communication.

4. Scope of Services Consent

I authorize a licensed dental hygienist, working within applicable law, professional standards, and appropriate provider collaboration, to provide preventive and palliative dental hygiene services in a home, facility, mobile, or office setting.

Potential services may include:

  • Oral-health assessment and preventive dental hygiene care
  • Prophylaxis and periodontal maintenance, when clinically appropriate
  • Oral-hygiene education and personalized preventive recommendations
  • Antibacterial gum irrigation, when clinically appropriate
  • Intraoral photographs and dental radiographs for documentation, assessment, treatment planning, and provider consultation
  • Silver Diamine Fluoride (SDF), if indicated and separately authorized
  • Teledentistry-supported consultation, documentation, and care coordination
  • Referral to a dentist, physician, emergency service, or other appropriate provider when needed

I understand that these services are intended to support preventive, palliative, and oral-health maintenance needs. They do not replace restorative or emergency dental treatment, including fillings, crowns, root-canal treatment, extractions, surgery, or treatment for acute infection.

I understand that the provider may determine that a service is not appropriate, cannot be completed safely, or requires referral to an in-person dentist, physician, or emergency provider.

5. Teledentistry Consent

I understand that teledentistry may be used as part of my dental care. This means a dentist or other appropriate provider may participate remotely through secure technology before, during, or after my appointment.

  • A dentist may be virtually present during my visit.
  • My complete diagnosis may not be available at the time of the appointment or immediately afterward.
  • I may have virtual access to a dentist during the appointment, but access after the service may be limited or asynchronous.
  • I consent to the taking, use, and secure transmission of photographs, radiographs, clinical information, and video recordings as reasonably needed to provide teledentistry-supported services.
  • My provider uses Teledentix and appropriate safeguards to protect patient information; however, teledentistry involves transmitting protected health information through secure electronic channels.
  • Teledentistry may not be clinically appropriate for every situation, and I may be referred before, during, or after the visit to an outside dentist, physician, medical provider, emergency provider, or in-person dental service.

6. Dental X-Ray Consent

I understand that dental radiographs (X-rays) may be recommended based on my oral-health condition, clinical findings, risk factors, prior records, and professional guidelines. Dental radiographs can help identify conditions that may not be visible during a visual examination, including decay, infection, fractured teeth, bone loss associated with periodontal disease, root abnormalities, and other pathology affecting the teeth and jaws.

I understand that declining recommended dental radiographs may limit a provider's ability to identify, assess, communicate about, and appropriately refer potential oral-health concerns. I understand that dental radiographs involve a low level of radiation exposure and that reasonable protective measures will be used to minimize exposure.

7. Silver Diamine Fluoride (SDF) Consent

I understand that Silver Diamine Fluoride, also called SDF, may be recommended to help slow or arrest certain areas of tooth decay.

  • SDF is intended to help slow or arrest tooth decay; it does not restore a tooth or replace restorative dental treatment.
  • SDF may permanently darken or stain areas of active tooth decay, weakened tooth structure, or areas of tooth breakdown.
  • Temporary staining of nearby soft tissue may occur.
  • SDF may require reapplication at intervals determined by clinical need.
  • A referral for restorative dental treatment may still be recommended.

Learn more about SDF: Silver Diamine Fluoride is a professionally applied topical agent that may be used as a non-restorative option to help arrest certain cavities. It does not rebuild the tooth and may permanently turn treated decay dark. Review the American Dental Association's patient information page here: American Dental Association — Silver Diamine Fluoride (SDF).

8. HIPAA and Privacy Acknowledgment

I understand that the Health Insurance Portability and Accountability Act of 1996 (HIPAA) provides protections for my protected health information (PHI). Luxury Tooth Booth Inc., its providers, and applicable technology platforms may create and maintain records related to my health history, symptoms, examinations, images, radiographs, assessments, treatment, treatment recommendations, referrals, billing, and future care planning.

My health information may be used or disclosed as permitted or required by law for treatment and care coordination, referrals or consultations, payment and billing, SuperBill preparation, healthcare operations, and legal or public-health requirements when applicable.

9. Collaborative Care and Information Sharing

I authorize the treating dental hygienist and applicable providers to share and exchange my relevant health information with licensed healthcare professionals and care coordinators involved in my care when needed for care coordination and planning, medical-dental integration, continuity of treatment, referrals, consultations, and second opinions.

This may include clinical notes and treatment records, dental radiographs and intraoral photographs, relevant health history, medications, diagnoses, oral-health findings, treatment recommendations, referrals, and billing documentation. Only information reasonably necessary for treatment, coordination, payment, healthcare operations, or other legally authorized purposes will be shared.

I understand that this authorization remains in effect unless revoked in writing, except to the extent action has already been taken in reliance on it.

10. Media and Electronic Communication Authorization

Clinical Images

I understand that clinical photographs and radiographs may be necessary for documentation, treatment planning, consultation, referral, and care coordination.

Electronic Communication

I understand that email and text messaging may be used for appointment scheduling, reminders, payment links, SuperBill delivery, and general care updates. Electronic communications may carry privacy risks despite reasonable safeguards.

11. Payment Agreement and SuperBill Acknowledgment

  • A SuperBill with dental procedure codes may be provided before or after each visit for documentation and potential insurance reimbursement.
  • A SuperBill is not a guarantee that an insurance carrier will reimburse any amount.
  • Payment requests may be sent through Zelle from a secure business bank account payable to Luxury Tooth Booth Inc., or through a secure Stripe payment link.
  • Unless another arrangement is confirmed in writing by Luxury Tooth Booth Inc., payment is due before the scheduled visit.
  • Services will not be rendered until required consent documentation and payment have been received, unless another arrangement has been approved in writing.
  • The patient or responsible party is responsible for verifying insurance coverage, submitting claims when applicable, and any amount not reimbursed by insurance.

12. Final Consent and Signatures

By signing below, I confirm that I have had the opportunity to ask questions, understand the information presented, and voluntarily consent to the services and authorizations selected in this form.

Typing your name here acts as your electronic signature.

Required fields are marked with an asterisk.

This form is intended for administrative use and should be reviewed by qualified Colorado legal and compliance counsel before implementation. If you would prefer not to send health details through a website, call 720-217-9000 and we will complete this with you directly.