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Primary Insurance Information

Dental Insurance

Dental Group #/ID #

Medical Insurance

Medical Group #/ID #

Insured Party

Sex/Birth Date

Male Female

SS#

Insured Party Address

Phone Number

Relationship to Patient

Employer

Employer's Phone Number

Secondary Insurance Information

Dental Insurance

Dental Group #/ID #

Medical Insurance

Medical Group #/ID #

Insured Party

Sex/Birth Date

Male Female

SS#

Insured Party Address

Phone Number

Relationship to Patient

Employer

Employer's Phone Number

Is todays visit related to an accident?

Is todays visit related to an accident?

Yes No

Date of Injury

Work Related

Yes No

Automobile

Yes No

Other

Insurance Company Handling this Claim

Claim Number:

Name/Telephone # of contact person

Responsible Party (if other than patient)

Person responsible for bill

Self Spouse Father Mother Other

Name

Birth Date / S.S.#

Telephone

Address

Health Information

Reason for today's visit

Height/Weight

Are you in good health today?

Yes No

Date of last physical exam

Has there been any change in your general health in the past year?

Yes No

Are you under a physician’s care for a particular problem?

Yes No

Have you ever had any serious illnesses, operations or hospitalizations?

Yes No

Medications

Please list any and all medications you are taking, including prescription medications, diet drugs, over-the-counter medications, herbal or holistic remedies, vitamins or minerals:

For Women only

Are you pregnant, or is there any chance that you may be pregnant?

Yes No

Are you nursing?

Yes No

If you are using oral contraceptives, it is important that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or other medication is complete. Please consult with your physician for further guidance.

Note

Please complete and sign the next page. You may print a copy of this form for your records, however please click the Complete and Send button to electronically send a completed copy to our office. Please either upload or bring a photo ID and your insurance cards to your appointment.

Authorization

I certify the above to be true and correct. I will not hold my doctor or any member of his staff responsible for any errors or omissions that I may have made in the completion of this form.

I hereby authorize and direct my insurance benefits to be paid directly to West Shore Oral and Maxillofacial Surgery Associates, P.L.C. I understand that I am financially responsible for charges not covered by this authorization. I understand the provider’s charge may exceed the insurance payment, and if greater than such payment, I will be responsible for that payment. I also authorize the release of information required for insurance purposes. I authorize the release of information to other providers, upon request, in conjunction with my care and treatment.

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 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.

Signature of patient (parent or guardian if minor)

Click to Sign

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

Please Print Name

truForm by PBHS

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Patient Information

Patient Information

Insurance Information

Primary Insurance Information

Secondary Insurance Information

Is todays visit related to an accident?

Responsible Party (if other than patient)

Health Information

Health Information

Do you have or have you ever had:

Are you using any of the following:

Medications

Are you allergic to, or have you had an adverse reaction to:

For Women only

Authorization

Note

Authorization

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Patient Disclosure Instructions

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Main Header

Patient Information

Patient Information

Insurance Information

Primary Insurance Information

Secondary Insurance Information

Is todays visit related to an accident?

Responsible Party (if other than patient)

Health Information

Health Information

Do you have or have you ever had:

Are you using any of the following:

Medications

Are you allergic to, or have you had an adverse reaction to:

For Women only

Authorization

Note

Authorization

Click to Sign

Patient Disclosure Instructions

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.