New Patient? Here Are Your Forms! | Winsome Henry-Ward DMD

Welcome to Dr. Henry-Ward’s gentle dental practice, where all your general and cosmetic dental needs can be addressed in one lovely location.

We are so happy you’re coming to see us! We just need some information from you to get started. By filling out our online forms, your arrival time can be moved up and we can begin your dental treatments sooner. Please note that your information is strictly confidential and secure. If you have any questions, please don’t hesitate to call. We are here for you and want to make this as easy as possible. 314-862-1118

Thank you for choosing our practice – we look forward to seeing you soon!

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Patient Information
Social Security Number or Member ID (on insurance card)*
Patient Name*
First Middle Last
Address*
Street Address City State ZIP Code
Email*
Sex*
Birthdate*
MM slash DD slash YYYY
Marital Status*
Number of years partnered
Patient Employer/School*
Occupation
Employer/School Address*
Street Address City State ZIP Code
Employer/School Phone*
Spouse/Partner's Name
First Last
Spouse/Partner's Birthdate
MM slash DD slash YYYY
Spouse/Partner's Social Security Number
Spouse's Employer
How did you hear about us?*
Do you have dental insurance?*

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Dental Insurance Information
Who is responsible for this account?*
Relationship to Patient*
Insurance Company*
Group #*
Is patient covered by additional insurance?*
Subscriber's Name*
First Last
Birthdate*
MM slash DD slash YYYY
Social Security Number*
Relationship to Patient*
Insurance Company*
Group #*
Assignment and Release
I certify that I, and/or my department(s), have insurance coverage with the above insurance company and assign directly to Dr. Henry Ward all insurance benefits, if any, otherwise payable to me for services rendered. I understand that I am financially responsible for all charges whether or not paid by insurance. I authorize the use of my signature on all insurance submissions.

The above named dentist may use my health care information and may disclose such information to the above named Insurance Company(ies) and their agents for the purpose of obtaining payment for services and determining insurance benefits payable for related services. This consent will end when my current treatment plan is completed or one year from the date signed below.
Signature of Patient, Parent, Guardian or Personal Representative*
Relationship to Patient*

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Phone Numbers
Cell*
Work
Home
In Case of Emergency, Contact
(Specify someone who does not live in your household).
Name*
First Last
Relationship*
Cell Phone*
Work Phone

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Medications
Are you currently taking any medications?*
List any medications you are currently taking and the correlating diagnosis:
Pharmacy Name*
Phone

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Allergies
Check the following:
- Aspirin
- Barbiturates (Sleeping pills)
- Codeine
- Iodine
- Latex
- Local Anesthetic
- Penicillin
- Sulfa
- Other
Other

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Our Financial Agreement
Insurance:
Should you have dental insurance, we will accept assignment of benefits, file your claims, assist you in maximizing your benefits & ESTIMATE your treatment as closely as possible. However, the relationship with your insurance company is between you, your employer and the insurance company. We are not party to that contract. If insurance has not paid in 45 days, the total amount due will be your responsibility. Your ESTIMATED portion is due in full, the day of your appointment.
Payment:
If you do not have dental insurance, you are expected to pay in full by cash, check or credit card the day of your appointment. No checks will be accepted over $100.00 at initial visit.
Deposit:
Any appointment that is one and a half (1 1/2) hours long or longer requires a deposit of (50%) of the estimated patient portion. This deposit is non-refundable unless (48) hour notice of cancellation is given.
Contractual Agreement
Please read the following information and sign below.
I authorize payment directly to Dr. Winsome A. Henry-Ward for the benefit otherwise payable to me under the terms of any insurance. I understand that I am financially responsible for all charges arising from the treatment of the below named individual and any insurance payments will be credited to the account. I understand that assistance with appeals to my insurance carrier, as needed, will be provided but I am ultimately responsible for the account.

I further understand that the office requires a minimum (48) hour advance notice for cancellation, otherwise it is considered a missed appointment. A fee of $25.00 will be charged. Please contact the office in advance. We do not double book our patients, so confirmation is vital.

In the event any check given in payment is returned by the bank unpaid for any reason, a $25.00 charge will be added to the account balance each time such a check is returned. If all charges are not paid within sixty (60) days from the date of service, I understand that I will pay the service charge of one and one-half (1.5) percent per month, eighteen (18) percent per year.
If your account is referred to a collection agency or attorney, I understand that I’m responsible for the following: the overdue balance, collection company costs and/or attorney fees plus, any and all court costs.

I have read and understand the above office financial policy. A copy will be provided at the office upon my request.
Signature*
First Last
Patient Name (if other than above)
First Last
If you are not the parent, please state your relationship to the patient

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HIPAA Agreement
Privacy Notice Summary
This is a summary of our Privacy Notice regarding patient’s protected health information. If you wish to read the notice in its entirety, please ask our receptionist for a copy.
Who Will Follow This Notice
This notice describes our policy regarding the use of your medical information. All physicians, employees, staff and other authorized personnel who may need access to your medical information are bound by this policy.
Our Pledge Regarding Medical Information
This notice describes our policy regarding the use of your medical information. All physicians, employees, staff and other authorized personnel who may need access to your medical information are bound by this policy.

We are required by law to 1) keep medical information that identifies you private; 2) give you notice of our legal duties and privacy practices with respect to medical information about you; 3) follow the terms of the notice that is currently in effect.
How We May Use and Disclose Medical Information About You
There are different ways that, by law, we may use and disclose medical information. Here are several examples:
- For treatment.
- For health care purposes.
- For notifying you of treatment alternatives.
- For individuals involved in your care or payment for your care.
- To avert a serious threat to health or safety.
- To military officials if you are in the military or are a veteran.
- For health oversight activities.
- For law enforcement.
- To Coroners, Medical Examiners and Funeral Directors.
- For protective services for the President, National Security and Intelligence Activities.
- For payment.
- For appointment reminders.
- For health-related benefits and services.
- For research (under certain circumstances).
- As required by law.
- For worker’s compensation claims.
- For lawsuits and disputes.
- To Prison officials of patients who are inmates.
There is a description of each of the above in the full version of this notice.
Rights Regarding Medical Information About You
You have rights regarding medical information we maintain about you:
- Right to inspect and copy.
- Right to amend.
- Right to an accounting of disclosures.
- Right to a paper copy of this notice both in summary and in complete version.
- Right to request restrictions.
- Right to request confidential communications.
Changes to This Notice
We reserve the right to change this notice. We reserve the right to make the revised or changed notice effective for medical information we already have about you, as well as any information we receive in the future. We will post a copy of the current notice. The notice will contain on the first page, in the top right-hand corner, the effective date.
Complaints
If you believe your privacy rights have been violated, you may file a complaint with our medical practice or with the Secretary of the Department of Health and Human Services. To file a complaint with our medical practice, please contact our Privacy Officer at 8390 Delmar Blvd., Suite 1001, St. Louis, MO 63124, (314) 997-1118. All complaints must be submitted in writing. You will not be penalized for filing a complaint.
Other Uses of Medical Information
Other uses and disclosures of medical information not covered by this notice or the laws that apply to us will be made only with your written permission. If you provide us permission to use or disclose medical information about you, you may revoke that permission, in writing, at any time. If you revoke your permission, thereafter we will no longer use or disclose medical information about you for the reasons covered by your written authorization. You understand that we are unable to take back any disclosures we have already made with your permission, and that we are required to retain our records of the care that we provided to you.
Patient Acknowledgement
- I have read this summary but do not wish to read the full version.
- I have read this summary and the full version.
- I have requested and received a copy of the summary.
- I have requested and received a copy of the full version.
Patient Name*
First Last

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What Our Patients Say

Very gentle, very competent. I am very appreciative of your skill and skill of your staff. Thanks.

Shawna Silva

Dr. Ward, I want you to know how much I appreciate the care I have received here. I am so happy with the improvement in my gums, and it is because of your emphasis on preventive oral care. It has made a huge difference, and I thank you.

Dave Diaz

Beginning in 1995 Dr. Ward took over my dental care. She has proven to be as painless as I believe possible. My bridges have performed perfectly. My extractions have been very few, and my partial is working without incident. I recommend that anyone needing dental work consider using Dr. Ward.

Rudolph Hughes

Since having my first traumatic experience as a 9 year old with an army dentist I was always anxious about going to the dentist; my muscles would get tense, and I would grip the arms of the dentist chair, anticipating the worst.
But what a difference Dr. Ward has made in my previously harrowing experiences with dentists. With her calm caring manner and soothing touch, I actually became more relaxed in the dentist chair. What a relief!

Then as a bonus, there are times she would softly hum a tune which even makes me more calm, like a mother soothing an anxious baby – I guess I must have been a big baby when it came to dentists, but not anymore! Thank God for Dr. Ward! And her friendly staff aren’t too bad either.

Deanna Little

One day during my morning prayer and meditation I had to look up the word honorable. The word is rich in meaning and implies the purest, highest, noblest kind of goodness. Honorable means “lovely”, “winsome”, “gracious”, “noble” and “excellent’. Your name, Winsome, definitely describes your character and your practice. God bless and keep you!!!

Jan Paul