General Patient Information
 Dr.   Mr.   Mrs.   Miss   Ms. 

Date:

 Male   Female 

Nearest Relative Not Living With You

Emergency Contact
Responsible For Account. if self, skip to next section
Insurance Information

Martial Status:

 Single   Married   Widowed   Divorced   Legally Separated 

Primary Dental Insurance Co. Name:

 Male   Female 

Primary Medical Insurance Co. Name:

 Male   Female 
Medical History

*Health problems or medication can have an important interrelationship with the care you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

ALLERGIES: Are you allergic or have you had a bad reaction to any of the following?:

Local Anesthetic (Numbing Med.)
Sulfa Drugs
Asprin
Soy
Penicillin
Sodium Pentothal, Valium or Other Tranquilizers
Codeine or Other Narcotics
Eggs/Yolk
Other Antibiotics
Latex
Sulfites

Please list all known allergies and reactions to medications:

I have no known allergies.

MEDICATIONS: Are you taking or have you ever taken any of the following?:

Blood Thinners (Coumadin, Plavix, Asprin, Vitamin E, Ginko Biloba)
Diet Pills
Any bone density medication/Bisphosphonates (Aredia,Zometa,Fossamax,Actonel, Evista,Prolia, Forteo)
Tranquilizers, Sleepig Pills, Anti-Depressants and/or Narcotics on a Regular Basis
If so, please list:
Please list all current medications, including non-perscription, homeopathic, and natural remedies:
Currently taking no medications

Reason for today's office visit:
Are you in good health?YesNo
Has there been any change in your general health in the past year?YesNo
Are you now under the care of a physcician?YesNo
- If yes, for what conditions?
Have you had any serious illnesses, operations or hospitializations in the past five years?YesNo
- If yes, please explain:
Do you have unhealed/recurent injuries or inflamed areas, growths or sore spots in or around your mouth?YesNo
- If yes, please explain:
Do you have a prosthetic joint/implant?YesNo
- If yes, please describe where:
Have you had a heart valve replacement or vascular graft?YesNo
Are you on a diet?YesNo
Do you wear contact lenses?YesNo
Do you wear a removable dental appliance?YesNo
Have you had or do you currently have:
Rheumatic Fever
Difficult Breathing
Thyroid Trouble
Delay in Healing
Damaged Heart Valve/Mitral Valve Prolapse
Other Lung Trouble
Diabetes
Stomach Ulcers
Tuberculosis
Low Blood Sugar
Kidney Trouble
Heart Murmur
Emphysema
On Dialysis
Eye Disease/Glaucoma
High Blood Preassure
Blood Transfusion
Swollen Ankles, Arthiritis Or Joint Disease
Tumor or Growth
Low Blood Pressure
Anemia/Other Blood Disorder
Radiation Thereapy or Chemotherapy
Chest Pain/Angina
Bruise Easily
Osteoporsis/Osteopenia
Heart Attack(s)
Bleeding Tendency
Osteonecrosis
Chronic Fatigue or Night Sweats
Irregular Heart Beat
Hepatitis, Jaundice or Liver Disease
Contagious Diseases
Cardiace Pacemaker
Sexually Trasmitted Diseases
Mental Health Problems
Heart Surgery
Infections Mononucleosis
Disease/Drug/Transplant that has Suppressed Immune System
Pain or Clicking of Jaws When Eating
Bronchitis or Chronic Cough
Gallbladder Trouble
Asthma
Fainting Spells
Immune System Trouble/Problems From Medication, Surgery, Etc.
Malignant Hyperthermia
Hay Fever/Sinus Problems
Convulsions/Epilepsy
Smoke or Chew Tobacco
Snoring/Sleep Apnea
Stroke
History of Drug Abuse
History of Alcohol Abuse
Notes for any of the above checked:

Is there a family history of:

Cancer
Diabetes
Heart Disease
Anesthetic Problems
Is there any condition concerning your health that the doctor should be told about?YesNo
- If yes, please describe:
Do you wish to speak to the doctor privately about anything about?YesNo

VISIT RELATED TO ACCIDENT:

if No, skip to next section.

Is this visit related to an accident?YesNo
If Yes:
Automobile
Work Related
Other

Date of injury:

Insurance Company handling this claim

Claim Number

Name of Attorney or Adjustor:

Phone #:

WOMEN ONLY:
Are you pregnant or is there any chance you might be pregnant?YesNo

-If yes, expecting delivery date:

Are you nursing?YesNo
Are you taking birth control pills?YesNo

Please Note: Antibiotics (such as Penicillin) may alter the effectiveness of birth control pill. Consult your physician or gynecologist for assistance regarding additional methods of birth control.

I certify that I have read and understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my surgeon, or any other member of the staff, responsible for any errors or omissions that I have made in the completion of this form.

(Parent or Legal Guardian If Minor)
Fees & Payments

Arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance, we will be glad to fill out the proper forms.

Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge.

It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees and court costs.

(Parent or Legal Guardian If Minor)

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

(Parent or Legal Guardian If Minor)
Authorization

I authorize my surgeon and his designated staff to perform an oral and maxillofacial examination, for the purpose of diagnosis and treament planning. Futhermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment.

(Parent or Legal Guardian If Minor)

I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice.

(Parent or Legal Guardian If Minor)
Appointment Cancellation & No-Show policy

The policy of this office is to require patients to give us notice of cancellation of any appointment within at least 48 hours from the scheduled appointment time.

It is further understood that if any patient fails to appear or cancels an appointment without at least 48 hours advance notification to this office, the following fees will be applied to your account with reasonable consideration of circumstances, including unforeseen emergencies or sickness.

(Please note that your insurance will not reimburse you for these fees.)

Appointments with a ½ hour block

Appointments with a 1 hour block

Appointments with a 1 ½ hour block

Appointments with a 2 hour block

$100.00

$150.00

$300.00

$500.00

This is a non-refundable charge and no further appointments will be made without the patient’s portion of the surgery being paid in full. The applied cancellation charge must also be paid at the time of rescheduling. If the appointment is cancelled within the 48 hours, the surgery fee will be reimbursed.

The signature of the patient and/or guardian below acknowledges the understanding of the above.

Insurance Patients

We will bill your insurance company for your visit AS A COURTESY to you.

We make every attempt to provide you with up-to date and accurate Insurance information; however, all fees quoted are estimates.

Insurance carriers frequently change their fees and coverage amounts without notifying us or you. It is up to you, the patient, to understand and double check all procedures, fees, insurance coverage, and to ensure that we are Participating provider with your insurance plan.

We make ask for your assistance in getting your claim paid.

Any remaining balance after insurance payment is solely the responsibility of the patient and must be paid in full.

Questions do arise and any issues or concerns with coverage should be Taken up directly with your insurance carrier.

By signing, I acknowledge this notice and agree to pay remaining balance in circumstances where insurance coverage is less than 100%.

(Parent or Legal Guardian If Minor)
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