Main Header

Section Two

Driver's License Number

Nearest relative not living with you

Employer / Business Phone

Personal Payment Type

Cash Check Credit Card

In Case of Emergency

Please Contact

Phone / Relation

Who will be responsible for your account?

Self Spouse Father Mother Other

Who will be responsible for your account

Name

Birth Date / Age / S.S.#

Responsible Party Phone

Email / Driver's License

Address

City / State / Zip

Employer / Phone

Spouse or other guarantor information (if different from above)

Name / Relation to Patient

Relation / Birth Date / S.S.#

Address

City / State / Zip

Phone

Employer / Business Name

Are you a student?

Full-time Part-time Not a student

School Information

School Name

School Address

City / State / Zip

Primary Dental Insurance Information

Employer

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 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 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 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

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

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

Conclusion

If you are having surgery today, have you had anything to eat or drink in the last 6 (six) hours?

Yes No

Who is driving you home?

Is there any condition concerning your health that the Doctor should be told about?

Yes No

Do you wish to speak to the Dr. privately about anything?

Yes No

Is there a family history of:

Cancer

Yes No

Diabetes

Yes No

Heart disease

Yes No

Anesthesia Problems

Yes No

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)

Click to Sign

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 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.

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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)

Click to Sign

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 infor-mation 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)

Click to Sign

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)

Click to Sign

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

Facial Pain & TMJ Questionnaire

Name

Referring Doctor

Primary Care Physician

Family Dentist

Please describe why you are here and when this began (chief complaint):

Narcotics Policy

By signing below, I understand that it is my responsibility to make sure that I have enough pain medication to make it through the night, weekend or holiday as the doctors of this practice will not prescribe any narcotics after office hours.

Patient's Name

Parent or Guardian (if minor) name

HIPAA Acknowledgement

I have received and reviewed this medical practice's privacy policy. I understand that my protected health information may be used in communications with other health care providers when medically necessary, for insurance reasons or for payment. I also understand the circumstances under which the practice may use this information, and that I have the right to withhold this consent if I do not want information released for purposes other than these legal requirements.

This practice may share my information with the individuals or healthcare practitioners below:
(Please provide full name and phone number )

Name / Phone

Special contact instructions (answering machine, etc.)

I understand that:
1) I have the right to place other restrictions on the release and use of my medical information and that I may request these in writing
2) These restrictions shall remain in effect until I change or modify them in writing.
3) I may review my medical record and ask staff to include any amendments or comments on my behalf to the written record.
4) This acknowledgement will expire in one year.

Patient's Name

Parent or Guardian name (if minor)

Patient or Legal Guardian (if minor) Signature

Click to Sign

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

HIPAA Privacy Notice effective 4/14/03, revised 8/26/08, 12/7/10

Main Header

Demographic Information

Patient information

Section Two

In Case of Emergency

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...

This section is for women only

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

Conclusion

Is there a family history of:

Is this visit related to an accident?

Verification

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Epworth Sleepiness Scale

EPWORTH SLEEPINESS SCALE

Facial Pain & TMJ Questionnaire

Facial Pain & TMJ Questionnaire

Narcotics Policy & HIPAA Acknowledgement

Narcotics Policy

HIPAA Acknowledgement

Click to Sign

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