Patient Info

Patient Forms & Information

Important Patient Documents can be accessed and downloaded below.

X-rays and records can be sent to:

Hitzel Dental Patient Info

New Patient Registration

Click to view and download New Patient Registration form (PDF).

Hitzel Dental Patient Info

HIPPA Patient Consent

Click to view and download HIPPA Patient Consent form (PDF).

Hitzel Dental Patient Info

Request of Records

Click to view and download Request of Records form (PDF).

Hitzel Dental Patient Info

Treatment of Minor Child

Click to view and download Treatment of Minor Child form (PDF).

Hitzel Dental Patient Info

Financial Consent

Click to view and download Financial Consent form (PDF).

Hitzel Dental Patient Info

Champagne Dental Club

Click to view plan details (PDF).

Instruction for patients following minor surgery or tooth extraction

Now that your oral surgery is completed, please follow these instructions to make yourself more comfortable, promote healing, and help prevent any possible complications.

If you have taken Halcion for your surgery, the effects of the medication may stay with you up to 8 hours. You should not operate machinery. It is best for you to rest and limit conversation. Speaking and chewing can cause bleeding.

You will have left this office with guaze covering the surgical site. Keep the guaze in place and apply pressure on it for 30 minutes. Wash hands and remove guaze after 30 minutes. A little bleeding or oozing is normal. If simple bleeding persists, use the provided extra guaze and apply pressure for another 20 minutes. Repeat if necessary, if bleeding is persistent, place a moistened tea bag to the area and apply pressure for 20 minutes. If bleeding continues please call us at 384-6656.

A nutritionally balanced soft diet with plenty of fluids is important during the first 24 hours. Eat soups and soft foods which are easily chewed and swallowed. Have foods warmed slightly rather than hot. During the first 24 hours avoid using straws, rinsing vigorously, smoking and alcohol. Any of these actions could disturb or dislodge the protective blood clot from the surgical site. Loss of clot (dry socket) may cause uncomfortable delayed healing, and require additional visits to our office for treatment. A meal supplement such as Ensure or Nurtrament may be helpful following the procedure depending on the amount of soreness you experience when chewing. Foods that are a good source of protein are: eggs, cottage cheese, pasta, lukewarm soups and ground meats.

During the next 5 days (beginning 24 hours after surgery) a lukewarm salt water rinse should be used 3-4 times a day. Dissolve one teaspoonful of salt to an eight ounce glass of warm water. Allow water to remain in your mouth for 60 seconds, but do not rinse vigorously before emptying salt water out of your mouth (do not spit). A gentle rinsing action is suggested.

Ice & Heat
Following surgery ice bags may be applied for 20 minutes, then removed for 20 minutes, continue alternating 20 minutes on, 20 minutes off until bedtime. Moist heat should be used beginning the second day if swelling is a problem. Do not use heat continuously, but you may use heat 20 minutes out of each hour. The third day is usually the most comfortable due to swelling. Some bruising may occur, this is normal.

If nausea occurs take one ounce of a carbonated drink every hour for five to six hours, along with two soda crackers, or drink mild tea or clear broth before resuming your regular diet.

Bone Fragments
Small bone fragments often separate from the surgical site during healing. If you feel a fragment or spicule in the surgical area it will probably work its way out. If it is sharp or painful, call for an appointment. Generally these fragments are easily removed without discomfort.

Please take medications as directed unless a drug reaction or allergies develop. If a drug reaction or emergency develops please call 384-6656. If you have trouble with breathing or feel extremely ill go the nearest hospital emergency room.

Should be avoided for the first 48 hours. Exercise can promote bleeding or discomfort. Start back slowly and develop a routine based on how you feel.

If you have any reaction to surgery or medication that you consider abnormal, please call 384-6656. If this occurs after hours, please leave a message with the answering service and your call will be returned. Our answering service can usually locate the Doctor on call within and hour or so.

We strongly believe in doing everything we possibly can to safeguard the privacy and security of your health information and records.

As a result, we have made some changes in our office management procedures to make sure we follow the Health Information Portability and Accountability Act (HIPAA). Passed into law in 1996, HIPAA sets federal standards for the privacy and security of patient information for all healthcare providers, plans, insurance companies and anyone they do business with.

HIPAA gives you additional rights regarding control and use of your health information, meaning you have more access and control than ever. Please take a few minutes to review these new rights. We’re happy to answer any questions you may have.

Control Over Your Health Information
All healthcare providers (and health plans) are now required to give you a written explanation of how they use and disclose your personal health information before they can treat you. This way, you can decide if a provider is doing everything they should to protect your privacy before you choose them as your caregiver.

We must, by law, post a Notice of Privacy Practices, which outlines how we secure the privacy of patient information, in a place where you can easily see it.

We must get your signature for non-routine uses and disclosures of your information. A non-routine use is any situation not directly related to treatment, payment or operations. For example, if your child is going to summer camp and the camp needs a medical history, you will be asked to authorize us to release it before we can send the information. You have the right to say no, and you don’t have to tell anyone why.

Authorizations of non-routine information are one-time-only, case by case, for the use defined by you.

Access To Your Health Information

You can get copies of your medical records simply by asking for them. Healthcare providers are required to get you a copy of your records within 60 days of your request. There may be a cost for this service. Providers also must give you a history of non-routine disclosures if you ask for it. All you need to do is ask for the record and it is provided to you – no justification is needed. You can also amend your medical records. You cannot change the existing record, but you can add notes Or comment On any procedures, treatments, payments or operations.

The provider then has the right to respond to your amendment. This way, you can be sure your records reflect your side of the story about treatment and payment issues.

Patient Recourse If Privacy Protections Are Violated

Every healthcare provider must also inform you of grievance procedures. If your privacy is violated, report the incident to our Privacy Officer immediately. You also have the right to report any violation to the Department of Health and Human Services, Office of Civil Rights, 200 Independence Avenue, S.W., Washington, D.C. 20201.

If you decide to file a grievance either with us or with the Department of Health and Human Services, we are not allowed to discriminate or retaliate against you in any way.

Aside from these new rights to access and control of your medical information under HIPAA, there are also clear limits on all healthcare providers regarding how they disclose medical information. Here are some of the key aspects of these boundaries: Providers must ensure that health information is not used for non-health purposes. Health information (covered by the privacy rules) generally may not be used for purposes not related to health care – such as disclosures to employers to make personnel decisions, or to financial institutions without your explicit authorization.

There are clear, strong protections against using health information for marketing. The privacy rules set new definitions, restrictions and limits on the use of patient information for certain marketing purposes. Providers must get your specific authorization before sending you any materials other than those related to treatment.

Use only the minimum amount of information necessary. In general, uses or
disclosures of information will be limited to the minimum necessary. This does not apply to disclosure of records for treatment purposes, because physicians, specialists and other providers may need access to the full record to provide quality care.

There are situations where healthcare providers may not have to follow these privacy rules. They include: emergency circumstances; identification of a body or the cause of death; public health needs; judicial and administrative proceedings; limited law enforcement activities; and activities related to national defense and security.

We understand your right to have your medical information kept confidential. Our compliance with the Health Information Portability and Accountability Act is one example of our advocacy and leadership on issues of patient’s rights and privacy of information. We encourage you to ask questions and look forward to working together to improve the quality of your healthcare experience.

If you don't see your carrier on this list, please call our office to inquire. (727) 535-3233

AARP Dental Plan
Aetna PPO
Aetna Dental Access – Vital Savings
Alliance Heathcard
Argus Insurance
Assurant PPO
Blue Cross PPO/Federal
Blue Cross Medicare Advantage

Carrington Dental
Carrington Discount Plan /500-501
Cigna PPO
Cigna Dental Access
CompBenefits : PPO, Advantage Plans
Connection Dental
Delta Dental PPO
Dent-All Plan
DHA/Assurant/Fortis: Direct Reimbursement
Direct Reimbursement
Encore Dental
FL. Combined Life
GE Financial
Healthplex PPO
Humana: Carrington

Humana Gold – DEN Plans
Liberty Dental / Wellcare
Lincoln Financial Group
Maverest PPO
Mutual of Omaha
Mutual Preferred
Principal Financial
Sun Life
United Healthcare PPO
United Concordia

We value your time and will do our best to accommodate your scheduling needs. Please be considerate of our time and other patients’ needs. If you are unable to make your appointment on time or at all, please give our office 24 hours advance notice so we may accommodate other patients. There may be a fee associated with missed patient appointments with out prior notice.

All services are to be paid at the time of service unless prior arrangements have been made with outside financing companies or your insurance carrier.

We accept Visa, Mastercard, Discover Card and CareCredit Financing.

Make your dream smile a reality!

Serving the communities of St. Petersburg, FL and Clearwater, FL

Call Champagne Dental Today!

St. Petersburg Office: (727) 384-6656
Clearwater Office: (727) 535-3233