Welcome!
We are delighted that you have contacted us regarding your dental needs. The decision to
choose a new dentist is not easily made. Sometimes it seems like the more you read the
more confusing things become.
Well let me assure you . . . you have come to the right place.
Recently, more and more dentists are advertising themselves to be “Mercury free” or
“Cosmetic” – yet few actually have the training and experience to back up these claims.
Whether you have concerns regarding your health, or you just want to improve the
appearance of your smile, Our Dr’s here at Integrative Dental Solutions has always been
on a quest to be on the cutting edge of modern dentistry.
So what sets us apart?
- Doctors that are open minded and spend time to listen
- Doctors that understand the need for continued learning
- A state of the art facility dedicated to your comfort & safety
- Advanced training in holistic & cosmetic dentistry with the country’s leading
experts (Huggins Alliance Fellow of AACP Accredited and SMART certified advanced training in
airway and cosmetic) Total Patient Comfort system
(Virtual Vision movie glasses, headphones, warm herbal neck wraps, etc.)
- A friendly, caring team
- Affordable financing (through CareCredit if qualified)
Enclosed is some information, so that you can get to know us a little better.
You come to our practice with high expectations; in order to meet these expectations and
deliver them in an affordable manner, we in return have high expectations of you. To get
the most out of your New Patient experience, it is critical that you review the enclosed
materials and fill out all forms as accurately as possible – there is even a checklist to make
sure that everything goes smoothly. Your commitment to better oral health starts here!
If you have any questions, please don’t hesitate to call.
We look forward to meeting you soon!
New Patient Checklist
Please use this checklist in order to make sure that you have reviewed all of
the enclosed patient education material and completed all necessary
paperwork. Good communication will be critical in ensuring that you will get
the most out of your New Patient experience.
You will have 30 minutes of time with the doctor at your initial examination and another
30 minutes at your consultation. This time is included in our “Gift of Health”. There is a
charge if additional doctor time is required to answer your questions. The good news is
that this should not be necessary if you have read the enclosed materials.
We offer all New Patients our “Gift of Health” special – a complete New Patient exam, all
necessary x-rays and a 30 minute consultation with one of the doctors for only $249. This
special is for patient of record only if you decide not to continue with care and would like
your xrays transferred you will be required to pay the full fee for your appointment which
is $520.00
This is a one-time offer only and for patient of record only.
If you cancel this appointment without proper notice (please see cancellation policy), or
do not show up on time, the fee to reschedule this appointment is $520.
Patient Introduction
Office Philosophy
Before we get started, it is important that you understand our philosophy of dental practice. In dental school, dentists
are trained to see the patient as a “set of teeth” and, with the exception of serious medical conditions, formulate
treatment plans regardless of the needs of the patient. We see your mouth as the key to your health. Gum
infections, tooth loss & decay, incompatible filling materials, and even an unattractive smile, can lead to less than optimal
health.
Your first appointment in our office will be a new patient exam. At this appointment, your doctor will sit down with you
to determine your exact needs and wants. Whether you are interested in conventional, high quality dentistry, or are
considering a biological/holistic approach, your doctor will formulate a treatment plan that is just right for you. Your
cleaning appointment can be scheduled following your new patient exam, so that our doctors can plan the type of
cleaning that would best support your needs.
Amalgam (Silver/Mercury Fillings)
Our office has been “Mercury Free” for over 15 years and “Mercury SAFE” for over 10 years. With the availability of
superior restorative materials and the controversy about mercury toxicity, Our dentists feel that placing amalgam fillings
is not in the best interest for their patients. This position is contrary to that of the American Dental Association and the
mainstream dental profession. If you have any concerns about the services we offer, we urge you to ask questions or
seek a second opinion.
Continuing Education
Until 2007, Wisconsin was one of the only a handful of states that had no requirements for continuing education. Sadly,
surveys showed that a majority of Wisconsin dentists did not attend post graduate education on a regular basis prior to
2007. Our doctors attend numerous hours of education annually to keep up with the latest techniques and materials
in dentistry.
About our Fees-
A holistic dental practice faces many challenges; maybe one of the biggest is how to make this type of dentistry
affordable. Hundreds of hours of continuing education, specialized equipment and supplies, as well as the need to spend
more time with each patient each contribute to making holistic dentistry more expensive. We have worked very hard to
be as efficient as possible. By using technology such as CEREC (CAD/CAM) and by completing either a quadrant or half of
the mouth in one sitting, we are able to keep our fees competitive with conventional dentistry. Please remember, the
quest for oral health will require a financial commitment on your part, but it will be worth it!
In order to serve you better, we need to know a little more about you.
I have read the above. I consent to a complete examination & necessary x-rays to accurately evaluate my dental condition.
Canceled and Failed Appointment Policy
Your Dr. is committed to providing their patients with quality dental care. We realize the
importance of your time and do everything possible to not keep you waiting. We also ask
that you value the time of your Dr. and our team.
Proper notice for canceled appointments must be given to our office in order to serve all
of our patients. When given proper notice, we are able to contact patients who are trying
to get an appointment in our office.
Appointment reminder calls are only a courtesy. It is YOUR responsibility to write down
and keep track of your scheduled appointments. If for some reason our office is not able to
confirm your appointment and you do not show for a scheduled appointment, you will be
assessed a “Failed Appointment Fee”.
Our office must receive no less than 2 business day notice when canceling an
appointment (5 business days for surgical appointments). Messages left on our answering
machine after hours canceling an appointment for the following day, or over the weekend
(Sat., Sun.) canceling an appointment for the following Monday, are not acceptable.
Please note that we are in the office Mondays from 8am to 4pm, Tuesday – Thursday 8am –
3pm and Fridays 8am-2pm.
The fees for failed appointments or appointments canceled without proper notice are:
Doctor and Specialized Hygiene appointments- 10% of the Total cost of the
appointment Oral Surgeon/Anesthesiology appointments- 50% of the Total cost of the
appointment Hygiene recall appointments- $50.00 non-refundable pre-payment required
for next appointment
Office Financial Policy
Your Dr. has formulated a treatment plan that will restore your mouth to optimal health. Quality dentistry is initially more
expensive, but by using a comprehensive, “do it right the first time” approach, we can save you unnecessary discomfort and
expenses in the future. And, by implementing the policies below, we are able to keep our fees as low as possible.
Our goal is to make quality dental care affordable for you!
To reserve your appointment, financial arrangements must be made at the time of scheduling
Option 1 - Pre-Payment: for the pre-payment of entire proposed treatment plan (some exclusions may apply). Payment is due at the time of scheduling.
- 5% Discount (using check or cash)
- 3% Discount with credit card
Option 2 - Financing:
- CareCredit Financing- 1 year deferred interest for transactions over $200.
You can apply for CareCredit here in the office without the need for additional forms. This can be done electronically or
with a short phone call.If you plan on using CareCredit please note that your application must be approved before
scheduling.
Option 3 - Pay as you go:
- 30% deposit due at the time of scheduling, the remaining balance to be paid on appointment day.
Refunds:
If payment is made by credit card and a refund is requested, a 3% credit card processing fee will be deducted from the refund. All refunds will be returned through the mail in the form of a check.
- We do not accept assignment of insurance benefits
- We are not in-network with any insurance plan
- We do not submit pre-treatment estimates
- We will submit a claim on your behalf the day of service
Your insurance company has 30 days to pay the claim and payment is sent to you.
We include all information for your insurance company to handle your claim without delay (i.e. narrative, x-rays
and pictures)
Finally - there is a $50 fee for all returned checks.
I have read, understand and agree to the above policies.
If You Have Insurance
As a courtesy and convenience to you, we will file your dental insurance claim for you. This claim will include everything your insurance company requires to process the claim (Including pictures, x-rays and a narrative if necessary). In order for you to be promptly reimbursed by the insurance company, the claim process is computerized and claims are sent out within a day or two of service. Note – being computerized allows us to attach copies of x-rays and pictures with the initial claim (rather than waiting for the insurance company to request them). This greatly expedites the claim handling process.
It is extremely important that you understand the following:
-
Our office is not an insurance driven practice, we choose not participate with insurance companies
as we do not want our patient care to be dictated by them. Therefore, all communication with
your insurance company is your responsibility including claim status checks.
-
Your insurance company has been given all the information necessary to process your claim and should not have to request more information.
-
UCR (Usual, customary and reasonable) fees may vary by as much as 300%! They do NOT represent average fees for this area; rather, they reflect what your insurance company is able or willing to pay.
-
While we present a treatment plan that best restores your mouth to health, the insurance company will usually only pay for the least expensive available treatment.
-
Some procedures, such as inlays or onlays may not be covered by insurance.
-
Because maximum benefits in dental insurance plans have not increased in 50 years (really!), the are usually inadequate for anything other than maintenance or preventive type treatments.
-
By law, your claim must be paid or rejected after 30 days, therefore, if your insurance company
has not paid on your claim after 30 days, regardless of the reason, contact your insurance
company immediately!
Remember, we are looking out for your best interest - the insurance company is looking out for theirs!
I have read and understand the above.
NOTICE OF PRIVACY PRACTICES
THIS NOTICE DESCRIBES HOW HEALTH INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY. THE PRIVACY OF YOUR HEALTH INFORMATION IS IMPORTANT TO US.
OUR LEGAL DUTY
We are required by applicable federal and state law to maintain the privacy of your health information. We are also required to give you this Notice about our privacy practices, our legal duties, and your rights concerning your health information. We must follow the privacy practices that are described in this Notice while it is in effect. This Notice takes effect (MM/DD/YR), and will remain in effect until we replace it.
We reserve the right to change our privacy practices and the terms of this Notice at any time, provided such changes are permitted by applicable law. We reserve the right to make the changes in our privacy practices and the new terms of our Notice effective for all health information that we maintain, including health information we created or received before we made the changes. Before we make a significant change in our privacy practices, we will change this Notice and make the new Notice available upon request.
You may request a copy of our Notice at any time. For more information about our privacy practices, or for additional copies of this Notice, please contact us using the information listed at the end of this Notice.
USES AND DISCLOSURES OF HEALTH INFORMATION
We use and disclose health information about you for treatment, payment, and healthcare operations. For example:
Treatment: We may use or disclose your health information to a physician or other healthcare provider providing treatment to you.
Payment: We may use and disclose your health information to obtain payment for services we provide to you.
Healthcare Operations: We may use and disclose your health information in connection with our healthcare operations. Healthcare operations include quality assessment and improvement activities, reviewing the competence or qualifications of healthcare professionals, evaluating practitioner and provider performance, conducting training programs, accreditation, certification, licensing or credentialing activities.
Your Authorization: In addition to our use of your health information for treatment, payment or healthcare operations, you may give us written authorization to use your health information or to disclose it to anyone for any purpose. If you give us an authorization, you may revoke it in writing at any time. Your revocation will not affect any use or disclosures permitted by your authorization while it was in effect. Unless you give us a written authorization, we cannot use or disclose your health information for any reason except those described in this Notice.
To Your Family and Friends: We must disclose your health information to you, as described in the Patient Rights section of this Notice. We may disclose your health information to a family member, friend or other person to the extent necessary to help with your healthcare or with payment for your healthcare, but only if you agree that we may do so.
Persons Involved In Care: We may use or disclose health information to notify, or assist in the notification of (including identifying or locating) a family member, your personal representative or another person responsible for your care, of your location, your general condition, or death. If you are present, then prior to use or disclosure of your health information, we will provide you with an opportunity to object to such uses or disclosures. In the event of your incapacity or emergency circumstances, we will disclose health information based on a determination using our professional judgment disclosing only health information that is directly relevant to the person’s involvement in your healthcare. We will also use our professional judgment and our experience with common practice to make reasonable inferences of your best interest in allowing a person to pick up filled prescriptions, medical supplies, x- rays, or other similar forms of health information.
Marketing Health-Related Services: We will not use your health information for marketing communications without your written authorization.
Required by Law: We may use or disclose your health information when we are required to do so by law.
Abuse or Neglect: We may disclose your health information to appropriate authorities if we reasonably believe that you are a possible victim of abuse, neglect, or domestic violence or the possible victim of other crimes. We may disclose your health information to the extent necessary to avert a serious threat to your health or safety or the health or safety of others.
National Security: We may disclose to military authorities the health information of Armed Forces personnel under certain circumstances. We may disclose to authorized federal officials health information required for lawful intelligence, counterintelligence, and other national security activities. We may disclose to correctional institution or law enforcement official having lawful custody of protected health information of inmate or patient under certain circumstances.
Appointment Reminders: We may use or disclose your health information to provide you with appointment reminders (such as voicemail messages, postcards, or letters).
PATIENT RIGHTS
Access: You have the right to look at or get copies of your health information, with limited exceptions. You may request that we provide copies in a format other than photocopies. We will use the format you request unless we cannot practicably do so. (You must make a request in writing to obtain access to your health information. You may obtain a form to request access by using the contact information listed at the end of this Notice. We will charge you a reasonable cost-based fee for expenses such as copies and staff time. You may also request access by sending us a letter to the address at the end of this Notice. If you request copies, we will charge you $30 and postage if you want the copies mailed to you. If you request an alternative format, we will charge a cost-based fee for providing your health information in that format. If you prefer, we will prepare a summary or an explanation of your health information for a fee. Contact us using the information listed at the end of this Notice for a full explanation of our fee structure.)
Disclosure Accounting: You have the right to receive a list of instances in which we or our business associates disclosed your health information for purposes, other than treatment, payment, healthcare operations and certain other activities, for the last 6 years, but not before April 14, 2003. If you request this accounting more than once in a 12-month period, we may charge you a reasonable, cost-based fee for responding to these additional requests.
Restriction: You have the right to request that we place additional restrictions on our use or disclosure of your health information. We are not required to agree to these additional restrictions, but if we do, we will abide by our agreement (except in an emergency).
Alternative Communication: You have the right to request that we communicate with you about your health information by alternative means or to alternative locations. {You must make your request in writing.} Your request must specify the alternative means or location, and provide satisfactory explanation how payments will be handled under the alternative means or location you request.
Amendment: You have the right to request that we amend your health information. (Your request must be in writing, and it must explain why the information should be amended.) We may deny your request under certain circumstances.
Electronic Notice: If you receive this Notice on our Web site or by electronic mail (e-mail), you are entitled to receive this Notice in written form.
Integrative Dental Solutions
ACKNOWLEDGEMENT OF RECEIPT OF
NOTICE OF PRIVACY PRACTICES
**You May Refuse to Sign This Acknowledgement**
I have recieved a copy of this office's Notice of Privacy Practices.
I,
have received a copy of this office’s Notice of Privacy Practices.
For Office Use Only
We attempted to obtain written acknowledgement of receipt of our Notice of Privacy
Practices, but acknowledgement could not be obtained because:
© 2002 American Dental Association
All Rights Reserved
Reproduction and use of this form by dentists and their staff is permitted. Any other use, duplication or distribution of this form by any other party requires the prior written approval of the American Dental Association.
Directions to Our Pewaukee Office
We are located in the Five Fields Plaza at 23770 Capitol Drive in Pewaukee, WI – at the intersections of Capitol Drive (190) and Highfield Drive.LOCATED IN THE BACK OF THE BUILDING
Please call office with any questions: 262-691-4555
When using GPS enter: Highfield Dr. Pewaukee WI.
We are just a short drive from numerous eateries such as Thunder Bay Grill, Applebee’s or Panera’s, About 10 minutes away is Good Harvest Market (www.goodharvestmarket.com) an organic food store with café and lunch menu.
Wildwood Lodge 262.506.2000
Holiday Inn 262.506.6300
Patient Consent for Use of Electronic Mail (e-Mail)
- Risk of using Email
Our practice offers patients the opportunity to communicate with clinicians by e-mail.
Transmitting patient information by e-mail, however, has a number of risks that
patients should consider before giving consent. These risks include, but are not limited
to:
- E-mail can be circulated, forwarded, and stored in numerous paper and electronicfiles.
- E-mail can be immediately broadcast worldwide and be received by both intended and unintended recipients.
- E-mail senders can misaddress e-mail.
- E-mail can be more easily falsified than handwritten or signed documents. e. Backup copies of e-mail may exist even after the sender or the recipient has deleted his or her copy.
- Employers and on-line services have a right to archive and inspect e-mails transmitted through their systems.
- E-mail can be intercepted, altered, forwarded or used without authorization or detection
- E-mail can be used to introduce viruses into computer systems.
- E-mail can be used as evidence in court.
- Conditions for the use of e-mail
Our practice will use reasonable means to protect the security and confidentiality of e-
mail information sent and received. However, because of the risks outlined above, we
cannot guarantee the security and confidentiality of e-mail communication, and will not
be liable for improper disclosure of confidential information that is not caused by
provider’s intentional misconduct. Thus, patients must consent to the use of e-mail for
patient information.
Consent to the use of e-mail includes agreement with the following conditions:
- All e-mails to or from the patient concerning diagnosis or treatment will be printed out and made part of the patient’s dental and medical record. Because they are a part of the dental and medical record, other individuals authorized to access the dental and medical record, such as staff and billing personnel will have access to those emails.
- We may forward emails internally to our staff and agents as necessary for diagnosis, treatment, reimbursement, and other handling. Our practice will not, however, forward emails to independent third parties without the patients prior written consent, except as authorized or required by law.
- Although we will endeavor to read and respond promptly to an e-mail from the patient, we cannot guarantee that any particular e-mail will be read and responded to within any particular period of time. Thus, the patient shall not use e-mail for dental and medical emergencies or other time sensitive matters.
- If the patient’s email requires or invites a response from us and the patient has not received a response within a reasonable time period, it is the patient’s responsibility to follow up to determine whether the intended recipient received the email and when the recipient will respond.
- The patient should not use e-mail for communication regarding sensitive dental and medical information, such as information regarding sexually transmitted diseases, AIDS/HIV, mental health, issues of abuse, developmental disability, or substance abuse.
- The patient is responsible for informing our practice of any types of information the patient does not want to be sent by email, in addition to those set out in (item e) above.
- The patient is responsible for protecting his/her password or other means of access to email. Our practice is not liable for breaches of confidentiality caused by the patient or any third party.
- Our practice shall not engage in e-mail communication that is unlawful, such as unlawfully practicing medicine across state lines.
- It is the patient’s responsibility to follow up and/or schedule an appointment if warranted.
- Instructions
To communicate by email the patient shall:
- Limit or avoid use of his/her employers computer.
- Inform our practice of changes in his/her email address.
- Put his/her name in the body of the e-mail.
- Include the category of the communication in the emails subject line, for routing purposes (e.g. billing question)
- Review the email to make sure it is clear and that all relevant information is provided before sending to provider.
- Inform us that the patient recieved email from our practice
- Take precautions to preserve the confidentiality of emails, such as using screen savers and safeguarding his/her computer password.
- Withdraw consent only by e-mail or written communication to Provider.
PATIENT ACKNOWLEDGMENT AND AGREEMENT
I acknowledge that I have read and fully understand this consent form. I understand the risks associated with the communication of e-mail between Provider and me, and consent to the conditions outlined herein. In addition, I agree to the instructions outlined herein, as well as any other instructions that Provider may impose to communicate with patients by email. Any questions I may have had were answered.
0: Does not apply to you and 1: Applies to you
Mouth
Body
New Patient Questionnaire
Please take the time to answer our new patient questionnaire, this helps us to understand why you have chosen our holistic dental office
and what your expectations are so we can better assist and meet your needs.
