I understand the importance of a truthful health history and that my dentist and his/her staff will rely on this information for treatment. I will not hold Carolina Oral and Maxillofacial Surgery Center, its providers, or its staff responsible for any errors or omissions that I may have made in the completion of this form. I certify that I fully read and understand English, I understand the questions and statements on this medical history form, and I have answered them truthfully.
Parent or guardian (if minor or developmentally delayed) or Language interpreter signature
FEES & PAYMENTS
Signature of patient: (Parent, if patient is under 18)
AUTHORITY FOR THE USE OF DISCLOSURE OF MY PROTECTED HEALTH INFORMATION (PHI)
Voicemail and text communication
I understand that if the message is not sent in an encrypted manner there is a risk it could be accessed inappropriately; I still elect to receive email communication as selected. In addition to the allowable disclosures described in the Notice of Privacy Practices, I hereby specifically authorize disclosure of my protected health care information to the persons indicated below.
Signature of patient (Parent, if patient is under 18)
NOTICE OF PRIVACY PRACTICES ACKNOWLEDGEMENT
Signature of patient (Parent, if patient is under 18)
ASSIGNMENT OF BENEFITS (IF APPLICABLE)
Signature of patient (Parent, if patient is under 18)
MEDICAID (IF APPLICABLE)
Signature of patient (Parent, if patient is under 18)
MEDICARE (IF APPLICABLE)
Signature of patient (Parent, if patient is under 18)
