ALL AREAS OF THIS QUESTIONNAIRE MUST BE COMPLETED TO ALLOW DR. GRIFFITHS TO GIVE PROPER DIAGNOSIS. _________________________________________________________________________________________________________ WE NEED TO KNOW ALL ABOUT YOU SO THAT WE CAN GIVE YOU THE BEST COMPREHENSIVE CARE POSSIBLE. _________________________________________________________________________________________________________ Because of HIPAA Federal regulations protecting your privacy, we wish to inform you that we will release no information about you without your consent. By agreeing to this consent, you permit the release of any information to or from your primary physician or dental practitioner as required including a full report of examination findings, diagnosis and treatment program to any referring or treating dentist or physician. You understand that you are financially responsible for all charges whether or not paid by insurance and charges are due at the time of your visit. Your dental practitioner may use your health care information and may disclose such information to your Insurance Company(ies) and their agents for the purpose of obtaining payment for service and determining insurance benefits or the benefits payable for related services. Some services are not covered under your individual policy and are your sole responsibility.