*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.
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
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.
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%.