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Rivers Bend Family Dental
14061 St Francis Blvd NW Ramsey, MN 55303
Book An Appointment
Meet Our Team
Dr. Andrea Wimmergren
Cosmetic Dental Bonding
Dental Bone Grafting
Full Mouth Reconstruction
Replace Teeth With Dentures
Botox And Fillers
What is Deep Teeth Cleaning
Botox And Fillers
Health History Form
" indicates required fields
Patient First Name:
Patient Last Name:
MM slash DD slash YYYY
Home Phone Number
Cell Phone Number
Social security #
District of Columbia
Northern Mariana Islands
U.S. Virgin Islands
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
Is the patient a minor
Parent or Guardian's Name
In case of emergency please contact:
How Did You Hear About Us?
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,
Are you under a physician's care now?
If yes, what is it for?
Have you ever been hospitalized or had a major operation?
If yes, what was the reason for hospitalization or operation?
Have you ever had a serious head or neck injury?
If yes, any concerns we should be aware of?
Are you taking any medications, pills, or drugs?
If yes, please list any medications or drugs you're currently taking
Do you take, or have you taken, Phen-Fen or Redux?
Have you ever taken Fosamax, Boniva, Actonel or any other medications containing bisphosphonates?
Are you on a special diet?
Do you use tobacco?
Do you use controlled substances?
Are you allergic to any of the following?
Codeine Sulfa Drugs
Acrylic Local Anesthetics
Do you have, or have you had, any of the following?
Artificial Heart Valve
Cold Sores/Fever Blister
Congenital Heart Disorder
Epilepsy or Seizures
Hepatitis B or C
High Blood Pressure
Hives or Rash
Low Blood Pressure
Mitral Valve Prolapse
Pain in Jaw Joints
Sickle Cell Disease
Swelling of limbs
Tumors or Growths
Have you ever had any serious illness not listed above?
If yes, please describe or name the illness
Pregnant/Trying to get pregnant?
Taking oral contraceptives?
Welcome to River's Bend Family Dental Clinic! Dental treatment is an excellent investment in an individual's medical and psychological well-being. Financial considerations should not be an obstacle to obtaining important health treatment. Being sensitive to the fact that people have different needs in fulfilling their financial obligations, we are providing the payment options listed below:
Mode of Payment
Payment in Full (without insurance):
Cash or Check -
A bookkeeping courtesy of 5% is given for payment in full at the time of treatment.
Credit Card -
We accept Visa, MasterCard, and Discover. (5% courtesy does not apply.)
Your out-of-pocket co-pay is due at the time of treatment. After your insurance claim has been processed, any remaining balance is due in full at that time.
Extended Payment Plan:
Dental Fee Plans -
We offer the Care Credit payment plan to qualifying candidates with interest-free financing for up to18 months. Please see our Office Manager for an application.
(Good credit standing required.)
Insurance Company Name
Plan Group #
* For dental work over $200.00. a current credit card number and expiration date is required. We will not carry an account balance past 90 days.
As a courtesy to our patients, all insurance forms wlll be filed on behalf of the patient by our office, free of charge.
Please be advised that regardless of your dental coverage, our Clinic relies on you for settling your account.
We have eliminated costly bookkeeping and billing fees by implementing the above policy. The savings is reflected in our fee schedule, thus maintaining reasonable fees for our patients.
Broken Appointment Policy:
There will be a $50 per appointment hour chair charge for failed appointments or appointments cancelled with a less than 24-hour notification.
COVID-19 SCREENING FORM
By signing this form I consent to the following:
1. I have not had or have been diagnosed with COVI D-19 in the last 14 days.
2. I do not have any of the following symptoms linked to COVID-19 listed below:
Loss of taste/smell
Shortness of Breath
3. I have not been in contact with anyone sick and/or confirmed to be positive with COVID-19.
4. I have not traveled to any regions affected by COVID-19 in the past 14 days.
I knowing and willingly consent to treatment with the full understanding and disclosure of the risks associated with receiving care during the COVID-19 pandemic. I confirm all of my questions were answered truthfully and to my satisfaction. This form has no expiration date.
I understand that I have certain rights to privacy regarding my protected health information.
These rights are given to me under the Health Insurance Portability and Accountability Act of 1996 (HIPAA).
I understand that by signing this consent, I authorize you to use and disclose my protected health information to carry out:
Treatment (including direct or indirect treatment by other healthcare providers involved in my treatment);
Obtaining payment from third party payers (e.g., my insurance company);
I have also been informed of, and given the right to review and secure a copy of your Notices of Privacy Practices, which contains a more complete description of the uses and disclosures of my protected health information, and my rights under HIPAA.
I understand that you reserve the right to change the terms of this notice from time to time and that I may contact you at any time to obtain the most current copy of this notice.
I understand that I have the right to request restrictions on how my protected health information is used and disclosed to carry out treatment, payment, and healthcare operations, but that you are then bound to comply with this restriction.
I understand that I may revoke this consent, in writing, at any time. However, any use or disclosure that occurred prior to the date I revoke this consent is not affected.