You the patient have the right to accept or reject dental treatment recommended by your dentist. Prior to consenting to treatment, you should carefully consider the anticipated benefits and commonly known risks of the recommended procedure, alternative treatments, or the option of no treatment. Do not consent to treatment unless and until you discuss potential benefits, risks, and complications with your dentist and all of your questions are answered. By consenting to treatment, you are acknowledging your willingness to accept known risks and complications, no matter how slight the chance of occurrence.

It is very important that you provide your dentist with accurate information before, during and after treatment. It is equally important that you follow our dentist's advice and recommendations regarding medication, pre and post treatment instructions, referrals to other dentists or specialists, and return for scheduled appointments. If you fail to follow the advice of your dentist, you may increase the chances of a poor outcome.

Certain heart conditions may create a risk of serious or fatal complications. If you (or a minor patient) have a heart condition or heart murmur, advise our dentist immediately so he can consult with your physician if necessary.

The patient is an important part of the treatment team. In addition to complying with the instructions given to you by this office, it is important to report any problems or complications you experience so they can be addressed by your dentist.

If you are a woman on oral birth control medication, you must consider the fact that antibiotics might make oral birth control less effective. Please consult with your physician before relying on oral birth control medication if your dentist prescribes, or if you are taking antibiotics.

Further, I understand that I am entering into a contractual relationship with Dr. Stern for professional care. I further understand that meritless and frivolous claims for dental malpractice have an adverse effect upon the cost and availability of dental care and may result in irreparable harm to a dental provider. As additional consideration for professional care provided to me by Dr. Stern, I agree not to advance, directly or indirectly, any false, meritless, and/or frivolous claim(s) of medical/dental malpractice against Dr. Stern.

Furthermore, should a dental malpractice case or cause of action be initiated or pursued, I agree to use expert witness(es) who practice primarily in the same speciality as Dr. Stern. Furthermore, I agree that these expert witnesses will be members in good standing of and adhere to the guidelines and/or code of conduct defined for expert witnesses by the ODA. In further consideration for this, Dr. Stern agrees to the same stipulations.

I acknowledge that monetary damages may not provide an adequate remedy for breach of this Agreement. Such breach may result in irreparable harm to the Doctor's reputation and business. Both Dr. Stern and I agree in the event of a breach to allow specific performance and/or injunctive relief. As with all healthcare treatment, there are commonly known risks and potential complications associated with dental treatment. No one can guarantee the success of the recommended treatment, or that you will not experience a complication or less than optimal result. Even though many of these complications are rare, that can and do occur occasionally.

Some of the more commonly known risks and complications of treatment include, but are not limited to the following:

1.	Pain, swelling or discomfort after treatment
2.	Infection in need of medication, follow-up procedures or other treatment
3.	Temporary, or rarely, permanent numbness, pain, tingling or altered sensation of the lip, face, chin, gums and tongue along with possible loss of taste
4.	Damage to adjacent teeth, restorations or gums
5.	Possible deterioration of your condition which may result in tooth loss
6.	The need for replacement of restorations, implants or other appliances in the future
7.	An altered bite in need of adjustment
8.	Possible injury to the jaw joint and related structures requiring follow-up care and treatment, or consultation by a dental specialist
9.	A root tip, bone fragment or a piece of a dental instrument may be left in your body, and may have to be removed at a later time if symptoms develop
10.	Jaw fracture
11.	If upper teeth are treated, there is a chance of sinus infection or opening between the mouth and sinus cavity resulting in infection or the need for further treatment
12.	Allergic reaction to anaesthetic or medication
13.	Need for follow-up treatment, including surgery

This form is intended to provide you with an overview of potential risks and complications. Do not sign this form or agree to treatment until you have read, understood, and accepted each paragraph above. Please discuss the potential benefits, risks and complications of recommended treatment with our dentist.

**THIS NOTICE DESCRIBES HOW MEDICAL INFORMATION ABOUT YOU MAY BE USED AND DISCLOSED AND HOW YOU CAN GET ACCESS TO THIS INFORMATION. PLEASE REVIEW IT CAREFULLY.

The health insurance Portability and Accountability Act of 1996(HIPPA) is a federal program that requires that all medical records and other individually identifiable health information used or disclosed by us in any form, whether electronically, on paper, or orally, are kept properly confidential. This Act gives you, the patient, significant new rights to understand and control how your health information is used. “HIPPA” provides penalties for covered entities that misuse personal health information. As required by “HIPPA” we have prepared this explanation of how we are required to maintain the privacy of your health information and how we may use and disclose your health information. We may use and disclose your medical records only for each of the following purposes: treatment, payment and health care operations.

1.	TREATMENTS: means providing, coordinating, or managing health care and related services by one or more health care providers. An example of this would include teeth cleaning services.
2.	PAYMENT: means such activities as obtaining reimbursement for services, confirming coverage, billing or collection activities, and utilization review. An example of this would be sending a bill for your visit to your insurance company for payment.
3.	HEALTH CARE OPERATIONS: include the business aspects of running our practice, such as conducting quality assessment and improvement activities, auditing functions, cost-management analysis, and customer service. An example would be an internal quality assessment review.

We may also create and distribute de-identified health information by removing all references to individually identifiable information. We may contact you to provide appointment reminders or information about treatment alternatives or other health-related benefits and services that may be of interest to you. Any other uses and disclosures will be made only with your written authorization. You have the following rights with respect to your protected health information, which you can exercise by presenting a written request to the privacy officer:

1.	The right to request restrictions on certain uses and disclosures of protected health information including those related to disclosures to family member, other relatives, close personal friends, or any other person identified by you. We are however, not required to agree to a requested restriction. If we do agree to a restriction, we must abide by it unless you agree in writing to remove it.
2.	The right to reasonable requests to receive confidential communications of protected health information from us by alternative means or at alternative locations.
3.	The right to inspect and copy your protected health information.
4.	The right to amend your protected health information.
5.	The right to receive an accounting of disclosures of protected health information.
6.	The right to obtain a paper copy of this notice from us upon request.

We are required by law to maintain the privacy of your protected health information and to provide you with notice of our legal duties and privacy practices with respect to protected health information. This notice is effective as of today and we are required to abide by the terms of the Notice of Privacy Practice currently in effect. We reserve the right to change the terms of our Notice of Privacy Practices ad to make the new notice provisions effective for all protected health information that we maintain. We will post and you may request a written copy of a revised Notice of Privacy Practices for this office. You will recourse if you feel that your privacy protections have been violated. You have the right to file written complaint with hour office, or with the Department of Health & Human Services, Office of Civil Rights, about violations of the provisions of this notice of the policies and procedures of our office. We will not retaliate against you for filing a complaint.

Please contact us for more information: For more information about HIPPA or to file a complaint.

The U.S. Department of Health and Human Services Office of Civil Rights. 20 Independence Ave, S.W. Washington, D.C. 20201 202*619*0257 toll free 1877-696-6775 ***revised 9/23/13***

*	I acknowledge that I have been provided a copy of Smile Brighter Willoughby Hills's Notice of Privacy Practices to view well as a copy to take home, which has an effective date of 09/23/2013, and which describes how my health information may be used and disclosed.
*	I understand that you have the right to change the notice of Privacy Practices at any time, that I will be provided a copy of any updated version, and that I may contact you at any time to request a current Notice of Privacy Practices.
*	My signature acknowledges that I have been provided with a copy of the Notice of Privacy Practices.