*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?:
Please list all known allergies and reactions to medications:
MEDICATIONS: Are you taking or have you ever taken any of the following?:
Is there a family history of:
if No, skip to next section.
Date of injury:
Insurance Company handling this claim
Name of Attorney or Adjustor:
-If yes, expecting delivery date:
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.
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.
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.
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.
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.