Lehigh Valley Oral Surgery & Implant Center

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Welcome to Our Practice!

At Lehigh Valley Oral Surgery and Implant Center we have the highest standards of care. We feel that every patient deserves this standard. This philosophy is reflected in our everyday practice. We only utilize instruments, sterile techniques, advanced imaging, and dental implants that have a long history of success. Treating our patients as if we were treating our own family members is the ideal we strive to achieve each day. Thank you for taking the time to come in and experience our Oral Surgery difference. Prior to completing your paperwork, please take a few moments to review the Notice of Privacy Practices, our office policies regarding communication, appointments, flexible payment options and insurances.

Appointments and Communication
In addition to reminding all patients of their scheduled appointments a week in advance, Dr. Chaudhry and his staff, follow-up with all patients after consultations and procedures. Please be sure to select your preferred method for us to contact you. Patients are kindly asked to confirm their appointment at least 48 hours prior to the date/time scheduled. Any appointments that are not confirmed within that timeframe, may be rescheduled by our office, based on scheduling demand. Failure to arrive for an appointment and same-day cancellations will result in a $25.00 deposit required to reschedule.

Payments
Payment for treatment is due the day services are rendered. It is our goal to assist all of our patients in obtaining the treatment they deserve. Therefore, we are pleased to offer several payment options: including Cash, Credit/Debit Card and third party financing to eligible patients through Care Credit and Lending Club patient financing. Applying for third party financing is easy and can be done online or in the office. With approval, there are several options including deferred interest plans.

Dental Insurance
Our office participates with most PPO insurances and discount plans. We are pleased to file insurance claims to all dental insurances and assist you in obtaining the maximum benefits specified in your contract for participating insurance. To best serve you, please keep the following in mind:
• Your insurance is a contract between you, your employer and your insurance company. We are not a party to that contract. We will do our best to estimate your coverage, and file your insurance claims on your behalf. Not all dental services are necessarily covered under your dental insurance plan. It is essential that you read and understand your coverage and pay special attention to any preauthorization requirements, exclusions and waiting periods.
• Our office policy states that you are totally responsible for your bill. The estimated patient portion of the fee is due at the time of service. If a balance remains after we receive payment from your insurance carrier, or in the event your insurance carrier denies coverage, we will notify you. Failure of your insurance carrier to reimburse our office within 30 days will result in our billing you directly for any remaining balance
• If your coverage changes for any reason, please notify our office immediately.

Patient Information

Name

Preferred Name

Home Address

City / State / Zip

Mobile / Home / Work Number

What is the best way to communicate with you?

Home Phone Mobile Phone Text Email

Sex

Male Female

Birth Date / SS#

What is the purpose of your visit?

In the event of an emergency, whom should we contact?

Name

Relationship

Home / Mobile / Work Number

Employment Information for Primary Insurance Holder

Employer Name / Phone

Person Financially Responsible for Account (Complete ONLY if different from patient information above)

Name of responsible party

Relationship to patient (Check)

Spouse Parent Other

Home Address

City / State / Zip

Home / Work / Mobile Number

Birth Date / SS#

Dental Insurance Information (Must be completed if copy of card is not provided)

Name of Subscriber

Relationship to patient

Subscriber's Birth Date

Employer Name

Insurance Plan Name

Insurance Co Phone Number

Claim Address

City / State / Zip

Group # / ID #

Medical Insurance Information (Must be completed if copy of card is not provided)

Name of Subscriber

Relationship to patient

Subscriber's Birth Date

Employer Name

Insurance Plan Name

Insurance Co Phone Number

Claims Address

City, State, Zip

Group # / ID #

Pharmacy Information

Name

Phone

Address

City, State, Zip

Medical History

Height / Weight

Name and location of your general dentist

Street Address

City / State / Zip

1. Date of last physical exam

Physician's Name

Physician’s Phone Number

2. Have you ever been hospitalized (if yes, explain below)?

Yes No

3. Have you been under the care of a medical doctor during the past two years?

Yes No

4. Have you ever had any excessive bleeding requiring special treatment?

Yes No

5. Women: Are you pregnant/trying to get pregnant/breast feeding?

Yes No

Verification

I understand the importance of a truthful health history and realize that incomplete information may have an adverse effect on my treatment. To the best of my knowledge, the information above is complete and accurate.

Typed name of patient or guardian (if patient is under age 18)

Name

Signature of patient or guardian (if patient is under age 18)

Click to Sign

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

I authorize Lehigh Valley Oral Surgery and Implant Center to discuss my personal health information with the individuals listed below. I understand that by leaving spaces blank, I am indicating my choice that I do not want my information shared with or released to anyone else.

Name

Relationship to Patient / Phone Number

Name

Relationship to Patient / Phone Number

Name

Relationship to Patient / Phone Number

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.