Macomb/Clinton Township Office

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Emergency Contact

Please Contact

Tel. / Relation

Who will be responsible for your account

Self Spouse Father Mother Legal Guardian Other

Name

Birth Date / Soc. Sec. #

Address

City/State/ZIp

Employer / Phone

Is this related to an accident?

Is this visit related to an accident?

Yes No

If Yes, indicate type of accident?

Automobile

Work related

Other

Date of Injury

Insurance Company / Claim #

Attorney / Adjustor & Phone

Primary Dental Insurance Information

Ins. Company Name

Policy I.D. Number

Group

Employer / Business

Subscriber’s Name

Relation / Birth Date

Sex

Male Female

Subscriber S.S. #

Address

Same

If Different: Address

City / State / Zip

Primary Medical Insurance Information

Ins. Company Name

Policy I.D. Number

Group

Employer / Business

Subscriber’s Name

Relation / Birth Date

Sex

Male Female

Subscriber S.S. #

Address

Same

If Different: Address

City / State / Zip

Do you have secondary dental or medical insurance?

Yes No

Secondary Dental Insurance Information

Ins. Company Name

Policy I.D. Number

Group

Employer / Business

Subscriber’s Name

Relation / Birth Date

Sex

Male Female

Subscriber S.S. #

Address:

Same

If Different: Address

City / State / Zip

Secondary Medical Insurance Information

Ins. Company Name

Policy I.D. Number

Group

Employer / Business

Subscriber’s Name

Relation / Birth Date

Sex

Male Female

Subscriber S.S. #

Address:

Same

If Different: Address

City / State / Zip

Health History

Patient Legal Name

Person Filling Out:

Self / Patient

Guardian / Other

Medical Power of Attorney

If Not Patient, Relationship

Reason for today’s office visit?

Height / Weight

PLEASE INDICATE ANY HEALTH ISSUES THAT APPLY FOR THE PATIENT:

Patient has been hospitalized in the past year?

Yes No

Patient has a prosthetic joint or heart valve replacement?

Yes No

Patient or a family member has had an unusual or serious reaction to general anesthesia?

Yes No

If any of the following categories is YES, please indicate the condition.

Diabetes:

Diabetes

Yes No

If yes, please indicate the condition

Type 1

Type 2

Pre-diabetic

Lung Disease:

Lung Disease

Yes No

If yes, please indicate the condition

Asthma

COPD

Emphysema

Chronic Bronchitis

Sarcoidosis

Pulmonary Embolism

Sleep Apnea:

Sleep Apnea

Yes No

If yes, please indicate the condition

Positive Sleep Study

CPAP

Sleep Appliance

Liver Disease:

Liver Disease

Yes No

If yes, please indicate the condition

Hepatitis

Fatty Liver

Cirrhosis

Liver Failure

Kidney Disease:

Kidney Disease

Yes No

If yes, please indicate the condition

Dialysis

Chronic Kidney Failure

Thyroid Disease:

Thyroid Disease

Yes No

If yes, please indicate the condition

Hypothyroid

Hashimoto’s Disease

Thyroid Removal

Hyperthyroid

Goiter

Bleeding Issues:

Bleeding Issues

Yes No

If yes, please indicate the condition

Anemia

Clotting Disorder

Von Willebrand’s

Factor 5 Deficiency

Sickle Cell

Deep Vein Thrombosis (DVT)

Autoimmune Issues:

Autoimmune Issues

Yes No

If yes, please indicate the condition

Lupus

Rheumatoid

Sjogren’s Syndrome

Bone Disorder:

Bone Disorder

Yes No

If yes, please indicate the condition

Osteoporosis

Osteoarthritis

Gastrointestinal Issues:

Gastrointestinal Issues

Yes No

If yes, please indicate the condition

Acid Reflux

Ulcers

Gastric Bypass

Gastric Band

History of Cancer:

History of Cancer

Yes No

If yes, describe

History of Head and / or Neck Radiation:

History of Head and / or Neck Radiation

Yes No

If yes, describe

Where

Developmental Issues:

Developmental Issues

Yes No

If yes, please indicate the condition

Cerebral Palsy

Autism

Blindness

Deafness

Other Medical Condition Not Addressed

Other Medical Condition Not Address

Yes No

If yes, describe

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

Medication #21

Medication #22

Medication #23

Medication #24

Medication #25

Medication #26

Medication #27

Medication #28

Medication #29

Please list any other medication or antibiotic you are allergic to or have been advised not to take

Drug / Reaction / When #1

Drug / Reaction / When #2

Drug / Reaction / When #3

Drug / Reaction / When #4

Drug / Reaction / When #5

Drug / Reaction / When #6

Drug / Reaction / When #7

Drug / Reaction / When #8

Drug / Reaction / When #9

List any surgeries, operations, or procedures you have undergone and when:

MEDICAL HEALTH HISTORY ACKNOWLEDGEMENT

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:-------------

If minor, relationship to patient

FEES & PAYMENTS POLICY

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.

Summit Oral & Maxillofacial Surgery, PC is only a part of a coordinated care team that may be required for all of my or the patient’s needs. I understand that I would also be responsible for payment for services provided by the general dentist, other dental practitioners, laboratories and pathology services (e.g. review of biopsy specimens), and/or hospitals, clinics and medical providers at other facilities, where I may need follow-up evaluation and additional treatment related to my care at Summit Oral & Maxillofacial Surgery or any complications I may encounter.

The signature below is my authorization for the release of information necessary to process my claim. I hereby authorize payment to the provider named or the benefits otherwise payable to me. Also, my signature below confirms I understand and agree with the FEES & PAYMENT POLICY as noted above

AUTHORIZATION POLICY

I authorize Summit Oral & Maxillofacial Surgery, PC, my provider 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. My signature below, confirms I understand and agree with the AUTHORIZATION POLICY for evaluation and treatment noted above.

CONSENT FOR PHOTOGRAPHY / RADIOGRAPHS

I hereby acknowledge that during the course of my treatment, photographic records and additional radiographic imaging may be taken. These images will be retained as a part of my clinical record. My identity and images will be protected as per corporate policy towards all clinical records. I understand that these images may be used for: research purposes, relevant scientific and dental literature publications, professional website, dental and oral surgical conferences and meeting presentations and for educational purposes with other dental professionals and education of other potential patients that come to our offices. The images may be modified in ethical practices such as realigning, rotating, cropping and color correction such as exposure and contrast

I understand that images may be taken, however, I do NOT want any images used in publications or presentations.

CANCELLATION, NO SHOW AND MISSED APPOINTMENTS

With the nature of an outpatient surgical office and allocation of time needed for completion of surgical services: missed appointments, “no shows” and last minute cancellations are disruptive to the practice and other patients. You are being advised that you (or the patient) may be dismissed from the practice and unable to make additional appointments if you (or the patient) fail to attend scheduled appointments without notifying the office at least one business day in advance.

I understand that failure to attend scheduled appointments without one business day notice may allow for dismissal form the practice and inability to schedule any future appointments.

Yes No

PRIVACY AND PERSONAL REPRESENTATIVE AUTHORIZATION FOR INFORMATION RELEASE POLICY

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. I understand that a copy of the Privacy Practices is available for me. My signature below confirms I understand and agree with the PRIVACY and PERSONAL REPRESENTATIVE AUTHORIZATION FOR INFORMATION RELEASE POLICY as noted above.

I decline to receive a copy of the office’s Notice of Privacy Practices.

PERSONAL REPRESENTATIVE AUTHORIZATION FOR INFORMATION RELEASE

Please list below anyone that you will allow us to discuss this account with and their relationship to you.

Name / Relationship

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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

Macomb/Clinton Township Office

Main Header

Demographic Information

Patient Information

Emergency Contact

Who will be responsible for your account

Is this related to an accident?

Insurance Information

General Insurance Information

Primary Dental Insurance Information

Primary Medical Insurance Information

Secondary Dental Insurance Information

Secondary Medical Insurance Information

Health History

Health History

PLEASE INDICATE ANY HEALTH ISSUES THAT APPLY FOR THE PATIENT:

Health History Part 2

Cardiac History:

Diabetes:

Lung Disease:

Sleep Apnea:

Liver Disease:

Kidney Disease:

Thyroid Disease:

Neurologic Disease:

Bleeding Issues:

Autoimmune Issues:

Bone Disorder:

Gastrointestinal Issues:

History of Cancer:

History of Head and / or Neck Radiation:

Developmental Issues:

Other Medical Condition Not Addressed

Medications / Allergies

Please list any medications you are currently taking

Are you allergic to, or had a reaction to:

Please list any other medication or antibiotic you are allergic to or have been advised not to take

List any surgeries, operations, or procedures you have undergone and when:

MEDICAL HEALTH HISTORY ACKNOWLEDGEMENT

MEDICAL HEALTH HISTORY ACKNOWLEDGEMENT

Click to Sign

FEES & PAYMENTS POLICY

AUTHORIZATION POLICY

CONSENT FOR PHOTOGRAPHY / RADIOGRAPHS

CANCELLATION, NO SHOW AND MISSED APPOINTMENTS

PRIVACY AND PERSONAL REPRESENTATIVE AUTHORIZATION FOR INFORMATION RELEASE POLICY

PERSONAL REPRESENTATIVE AUTHORIZATION FOR INFORMATION RELEASE

Click to Sign

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