As required by law, our office adheres to written policies and procedures to protect the privacy of information about you that we create, receive, or maintain. Your answers are for our records only and will be kept confidential subject to applicable laws. Please note that you will be asked some questions about your responses to this questionnaire and there may be additional questions concerning your health. This information is vital to allow us to provide appropriate care for you. This office does not use this information to discriminate.
Patient Information
If you are completing this form for another person, what is your relationship to that person?
Referral Information
Referred By
Dental Information
Medical Information
Women Only Are you:
Allergies Please mark "Yes" if you are allergic to (or have had a reaction to) the following.
Please mark "Yes" if you have (or have had) any of the following diseases or problems.
Pharmacy Information
Conclusion
I certify that I have read and I 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 doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form.
FAILURE TO COMPLETE THIS FORM PRIOR TO YOUR VISIT MAY RESULT IN DELAYED OR CANCELLED APPOINTMENT
FEES & PAYMENTS: It is your responsibility to know your insurance coverage and benefits. Please verify your coverage with your insurance carrier prior to any procedure or surgery. All copays and deductibles are to be paid at the time of your surgery. If you have no insurance coverage, payment is due at the time of service. If your procedure is estimated to be over $500 a deposit of half of the estimated amount due will be required at the time of scheduling or when the benefits are determined. A 1.5% interest charge per month will be added to your account for any remaining balance after 60 days. If fees for service are deemed not covered or not medically necessary by your insurance carrier, this statement serves as notice that you will be financially responsible for all fees related to your plan of treatment. If your account is referred to a collection agency you will be responsible for collection fees up to 20% of the collection balance, court costs and attorney fees.
If for any reason you are unable to keep this appointment, please call our office as soon as possible. There may be a charge for appointments canceled less than 48 hours prior to the scheduled time.
I HAVE READ AND UNDERSTAND THE FINANCIAL POLICY.
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.
AUTHORIZATION: I authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, 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 to my other doctors and/or insurance carriers.
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.
ADVANCED DIRECTIVES: Because we are an outpatient facility we do not honor a “No Code Directive”. All life threatening emergencies will be transferred to an appropriate hospital.
All parties involved agree that this document may be signed electronically. The electronic signatures appearing on this document are the same as handwritten signatures for the purposes of validity, enforceability, and admissibility.
