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In Case of Emergency

Contact:

Phone / Relation

Who will be responsible for your account

Who will be responsible for your account?

Self Spouse Father Mother Other

Name

Birth Date / S.S.#

Responsible Party Phone

Email / Driver's License

Address

City / State / Zip

If you have insurance, please bring all MEDICAL AND DENTAL CARDS to your appointment.

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

LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING:

LIST ANY ALLERGIES NOT PREVIOUSLY LISTED:

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.

FEES & PAYMENTS
An estimation of your recommended treatment will be provided after your consultation with the doctor. You will be responsible for paying that amount on the day of service. If you have medical or dental insurance, please bring your cards with you to your appointment.

Please note, we have opted out of participating with Medicare and Medicaid. By signing below you agree that you will not submit or request that we submit a claim to Medicare, Medicaid, or its agents for services provided here.

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.

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.

AUTHORIZATION TO RELEASE PRIVATE HEALTH INFORMATION
You have my permission to discuss/disclose my medical treatment, medical records and/or billing with the follow family member, friend, or personal representative: (If you do NOT want any information discussed/disclosed, please write NONE)

Full Name

Relation/Phone

Full Name

Relation/Phone

Full Name

Relation/Phone

Signature of patient (Parent or Guardian if Minor)

Click to Sign

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

truForm by PBHS

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Demographic Information

Patient information

In Case of Emergency

Who will be responsible for your account

Insurance Information

Health History

Health History

Health History Part 2

This Section Is for Women Only

HAVE YOU EVER HAD, OR DO YOU CURRENTLY HAVE:

Medications / Allergies

Medications (Are you now taking...)

LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING:

Are you allergic to or had a reaction to:

LIST ANY ALLERGIES NOT PREVIOUSLY LISTED:

Conclusion

Verification

Click to Sign

PBHS truForm is best utilized in portrait mode.

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Main Header

Demographic Information

Patient information

In Case of Emergency

Who will be responsible for your account

Insurance Information

Health History

Health History

Health History Part 2

This Section Is for Women Only

HAVE YOU EVER HAD, OR DO YOU CURRENTLY HAVE:

Medications / Allergies

Medications (Are you now taking...)

LIST ANY MEDICATIONS YOU ARE CURRENTLY TAKING:

Are you allergic to or had a reaction to:

LIST ANY ALLERGIES NOT PREVIOUSLY LISTED:

Conclusion

Verification

Click to Sign

PBHS truForm is best utilized in portrait mode.

Please rotate your device to portrait orientation to begin.

You are in Private Browsing mode.

This form requires that you disable private browsing to continue. Please open a new browser window and reload the form.

This form requires that you disable private browsing to continue.
Please open a new browser window and reload the form.