Westwood Oral Surgery Associates, P.A.

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Douglas H. Seeger, DMD, MD

Kristine A. Gleason, DMD, MD

Gino A. Inverso DMD, MD

Diplomates American Board of Oral and Maxillofacial Surgery

COVID-19 Pandemic Dental Treatment Notice and Acknowledgement of Risk Form

The World Health Organization has characterized the COVID-19 virus, also known as “Coronavirus,” as a pandemic. Our practice wants to ensure you are aware of the risks of exposure to COVID-19 associated with receiving treatment during this pandemic.

COVID-19 is highly contagious and has a long incubation period. You or your healthcare providers may have the virus, not show symptoms and yet still be highly contagious. COVID-19 can result in a life-threatening respiratory disease in some patients. You may be exposed to COVID-19 at any time or in any place. Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

Dental procedures can create fine water spray or “aerosols” which may remain in the air for several minutes to hours. These aerosols may contain the COVID-19 virus and may create a risk of COVID-19 exposure. You cannot wear a protective mask over your mouth to reduce exposure during treatment as your healthcare providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.

To provide a safe environment for our patients and staff, this practice follows the applicable state and federal regulations and protocols for infection control, universal personal protection, and disinfection. However, due to the nature of the procedures we provide, it may not be possible to maintain social distancing between patients, doctors, and staff at all times.

Patient Acknowledgement

I acknowledge that I have read the Notice above and that I understand and accept that there is an increased risk of COVID-19 exposure with treatment during the pandemic.

I understand and accept the increased risk of COVID-19 exposure with treatment at this office.

I also acknowledge that I could, or may have, exposure to COVID-19 from outside this office and unrelated to my visit here.

Signature of patient (Parent or Guardian if Minor)

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

Patient Information

Prefix

Mr. Mrs. Ms. Dr.

Name

Sex

Male Female

Birth Date / Age / Social Security #

Mailing Address

City / State / Zip

Phone Number

Have you ever been a patient of our practice?

Yes No

Driver's License Number

Referred By

Dentist Name

Dentist City

Medical Doctor Name

Medical Doctor City

Orthodontist Name

Preferred Pharmacy / Phone

Employer / Business Name

In Case of Emergency

Please Contact

Phone / Relationship to patient

Who will be responsible for your account?

Self Spouse Father Mother Other

Who will be financially responsible for you account

Name

S.S. #/ Birth Date / Age

Responsible Party Phone

Email / Driver's License

Address

City/State/Zip

Employer / Phone

General Insurance Information

Marital status

Married Divorced Widow Single Legally Separated

Employed

Full Time Part Time Retired Not

Are you a student?

Full Time Part Time Not a student

School Information

School Name

School Address

Primary Dental Insurance Information

Insured Party

Relationship to patient / DOB

Insured Party Sex

Male Female

SSN / Phone

Insured Party Address

City / State / Zip

Employer / Business

Phone Number

Employer Address

City / State / Zip

Business Phone

Plan Name

Ins. Company Name

Policy I.D. Number

Insurance Address

City / State / Zip

Group

Primary Medical Insurance Information

Insured Party

Relationship to patient / DOB

Insured Party Sex

Male Female

SSN / Phone

Insured Party Address

City / State / Zip

Employer / Business

Phone Number

Employer Address

City / State / Zip

Business Phone

Plan Name

Ins. Company Name

Policy I.D. Number

Insurance Address

City / State / Zip

Group

Do you have secondary dental or medical insurance?

Yes No

Secondary Dental Insurance Information

Insured Party

Relationship to patient / DOB

Insured Party Sex

Male Female

SSN / Phone

Insured Party Address

City / State / Zip

Employer / Business

Phone Number

Employer Address

City / State / Zip

Business Phone

Plan Name

Ins. Company Name

Policy I.D. Number

Insurance Address

City / State / Zip

Group

Secondary Medical Insurance Information

Insured Party

Relationship to patient / DOB

Insured Party Sex

Male Female

SSN / Phone

Insured Party Address

City / State / Zip

Employer / Business

Phone Number

Employer Address

City / State / Zip

Business Phone

Plan Name

Ins. Company Name

Policy I.D. Number

Insurance Address

City / State / Zip

Group

Women Only

Is there a possibility of pregnancy?

Yes No

Expected delivery date?

Yes No

Are you nursing?

Are you taking birth control pills?`

Yes No

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

Yes No

Please answer YES to this question to fill in Medication information

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

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Medication #16

Medication #17

Medication #18

Medication #19

Medication #20

Medication #21

Medication #22

Medication #23

Medication #24

Medication #25

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 this visit related to an accident?

Yes No

If Yes, what type of accident?

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.

Signature of patient (Parent or Guardian if Minor)

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

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 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 den-tal and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.

Patients are required to provide insurance information at the time of the visit. If you cannot provide proper or complete medical and dental information, payment will be expected at the time of service.

If you are required to submit a referral and cannot do so at the time of your visit, any charges incurred will become your responsibility.

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.

Signature of patient (Parent or Guardian if Minor)

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

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.

Signature of patient (Parent or Guardian if Minor)

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

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

Signature of patient (Parent or Guardian if Minor)

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

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.

Signature of patient (Parent or Guardian if Minor)

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

Westwood Oral Surgery Associates, P.A.

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Covid-19 Questionnaire

Patient Disclosures

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COVID-19 Pandemic Dental Treatment Notice and Acknowledgement of Risk Form

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Demographic Information

Patient Information

In Case of Emergency

Who will be financially responsible for you account

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 ever had or do you currently have...

Have you ever had or do you currently have...

Women Only

Medications / Allergies

Medications (Are you now taking...)

Are you allergic to 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 this visit related to an accident?

Verification

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Click to Sign

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