Silicon Valley Surgical Arts

Main Header

Patient’s Name

Date of Birth

Patient’s Name

Date of Birth

What is the patients’ current vaccination status? (Please select one):

Not vaccinated 1st Dose 2nd Dose Booster

Please list the name of the vaccine(s)

What dates were they administered?

I fully understand and acknowledge the above information, risks and cautions and have disclosed to my provider any other conditions in my health history. By signing this document, I acknowledge that the answers I have provided above are true and accurate

Patient or Legal Representative Signature

Click to Sign

Date:-------------

Print Patient or Legal Representative Name/Relationship

Witness Signature (optional)

Click to Sign

Date:-------------

Who will be responsible for your account?

Self Other

Spouse or other guarantor information (if different from above)

Name / Relation

Birth Date / S.S.# / Phone

Employer / Bus. Tel.

Address

City/State/Zip

Primary Dental Insurance Company

Employer / Business

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Insured Party Sex

Male Female

Phone / Social Security #

Primary Medical Insurance Company

Employer / Business

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Insured Party Sex

Male Female

Phone / Social Security #

Secondary Dental Insurance Information

Employer / Business

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Insured Party Sex

M F

Phone / Social Security #

This section is for women only

Is there a possibility of pregnancy?

Yes No

Expected delivery date?

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other methods of birth control.

Are you taking any kind of medication, drug, pills?

Yes No

Please list any medications you are currently taking

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication #7

Medication #8

Medication #9

Medication #10

Medication #11

Medication #12

Is there a FAMILY history of

Cancer

Yes No

Diabetes

Yes No

Heart Disease

Yes No

Anesthesia Problems

Yes No

Verification

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.

Fees & Payments
We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other 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, but please complete the identifying information on this form.

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.

insurance payment Authorization
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.

notice of privacy practices
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. (click here to see our Notice of Privacy Practices HIPAA form)

Signature of patient (Parent or Guardian if Minor)

Click to Sign

Date:-------------

truForm by PBHS

Silicon Valley Surgical Arts

Main Header

COVID-19 Pandemic Patient Disclosures

Click to Sign

Click to Sign

Demographic Information

Patient information

Spouse or other guarantor information (if different from above)

Insurance Information

Primary Dental Insurance Company

Primary Medical Insurance Company

Secondary Dental Insurance Information

Health History

Health History

Health History Part 2

Have you had or do you currently have...

Have you had or do you currently have...

Medications / Allergies

This section is for women only

Medications (Are you now taking...)

Allergies (Have you had an allergic reaction, I.E. rash or itching, to any of the following)

Please list any medications you are currently taking

Conclusion

Is there a FAMILY history of

Verification

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.

Silicon Valley Surgical Arts

Main Header

COVID-19 Pandemic Patient Disclosures

Click to Sign

Click to Sign

Demographic Information

Patient information

Spouse or other guarantor information (if different from above)

Insurance Information

Primary Dental Insurance Company

Primary Medical Insurance Company

Secondary Dental Insurance Information

Health History

Health History

Health History Part 2

Have you had or do you currently have...

Have you had or do you currently have...

Medications / Allergies

This section is for women only

Medications (Are you now taking...)

Allergies (Have you had an allergic reaction, I.E. rash or itching, to any of the following)

Please list any medications you are currently taking

Conclusion

Is there a FAMILY history of

Verification

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.