NORTHERN NEVADA ORAL AND MAXILLOFACIAL SURGERY

Main Header

Section Two

Driver's License Number

Nearest relative not living with you

Employer / Business Name

Personal Payment Type

Cash Check Credit Card

Who will be responsible for your account?

Self Spouse Father Mother Other

Who will be responsible for your account

Name / Social Security Number

Birth Date / Age

Responsible Party Phone

Email / Driver's License

Address

Employer / Phone

Spouse or other guarantor information (if different from above)

Name / Relation to Patient

Birth Date / Social Security # / Phone

Address

Employer / Business Name

Are you a student?

Full-time Part-time Not a student

School Information

School Name

School Address

Primary Dental Insurance Information

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

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 #

Insured Party Address

City / State / Zip

Primary Medical Insurance Information

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

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 #

Insured Party Address

City / State / Zip

Do you have secondary dental or medical insurance?

Yes No

Secondary Dental Insurance Information

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

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 #

Insured Party Address

City / State / Zip

Secondary Medical Insurance Information

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

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 #

Insured Party Address

City / State / Zip

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

Medication #13

Medication #14

Medication #15

Medication #16

Medication #17

Medication #18

Medication #19

Medication #20

Please list any other medications or antibiotics you are allergic to

Medication / Antibiotic Allergy #1

Medication / Antibiotic Allergy #2

Medication / Antibiotic Allergy #3

Medication / Antibiotic Allergy #4

Medication / Antibiotic Allergy #5

Medication / Antibiotic Allergy #6

Medication / Antibiotic Allergy #7

Medication / Antibiotic Allergy #8

Medication / Antibiotic Allergy #9

Medication / Antibiotic Allergy #10

Is there a FAMILY history of

Cancer

Yes No

Diabetes

Yes No

Heart Disease

Yes No

Anesthesia Problems

Yes No

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 additional methods of birth control.

In case of emergency

Contact:

Phone / Relation

Is this related to an accident?

Yes No

If Yes, What type?

Automobile

Work related

Other

Date of Injury

Insurance Company / Claim #

Attorney / Adjustor & Phone

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.

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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.

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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.

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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 permit messages to be left on my phone and / or mobile phone concerning my appointment.

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√

I permit the office to communicate with me via text message on my cell phone.

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.

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Northern Nevada Oral & Maxillofacial Surgery

Reno Office
5456 Reno Corporate Drive
Reno, NV 89511
(775) 825-0285

Sparks Office
4840 Vista Blvd, Ste 108
Sparks, NV 89436
(775) 236-2511

Patient Privacy Policy

This signed statement will be included in your medical records chart. Our office will require your written consent before we use or disclose to others your medical information. However, we may need to disclose medical information or personal information for purposes of providing or arranging for your health care, for payment or reimbursement for the care we provide to you, and related administrative activities supporting your treatment. We may be required or permitted by certain laws to use and disclose medical information for other purposes without your consent or authorization.

As a member if AAAASF, Dr. Galea is required to participate in peer review and quality assurance activities. Confidentiality of these activities will be preserved by all members of the medical staff and others involved.

I hereby acknowledge that I have received a copy of Dr. Galea’s Notice of Privacy Practices. I have been given the opportunity to ask any questions I have regarding this notice.

Print Patient Name

Patient Date of Birth

Signature of Patient/Responsible Party

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

Relationship to Patient

Please indicate to whom you would like us to release your personal medical information:

Name

Relationship to Patient

Patient/Guardian Signature

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

Main Header

Demographic Information

Patient information

Section Two

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

Insurance Information

General Insurance Information

School Information

Primary Dental Insurance Information

Primary Medical Insurance Information

Secondary Dental Insurance Information

Secondary Medical 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

Medications (Are you now taking...)

Are you allergic or had a reaction to:

Please list any medications you are currently taking

Please list any other medications or antibiotics you are allergic to

Conclusion

Is there a FAMILY history of

This section is for women only

In case of emergency

Is this related to an accident?

Verification

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Northern Nevada Oral & Maxillofacial Surgery

Patient Privacy Policy

Patient Privacy Policy

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Consent for Oral Surgery and Anesthesia

Consent for Oral Surgery and Anesthesia

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