Main Header

In Case of Emergency

Please contact:

Tel. / Relation

Who will be responsible for your account?

Self Spouse Father Mother Other

Who will be responsible for your account

Name

Birth Date / Age / Soc. Sec. #

Responsible Party Phone

Email / Drivers License

Address

City / State / Zip

Employer / Business Name

Spouse or other guarantor information (if different from above)

Name

Relation to Patient / Tel.

Birth Date / Soc. Sec. #

Address

City / State / Zip

Employer / Business Name

Primary Dental Insurance Company

Employer

Business Address

City / State / Zip

Phone Number

Plan Name

Insurance Co. Name

Insurance Co. Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Insured Party Sex

Male Female

Insured Party Address

City / State / Zip

Phone / Soc. Sec. #

Policy I.D. Number

Secondary Dental Insurance Company

Employer

Business Address

City / State / Zip

Phone Number

Plan Name

Insurance Co. Name

Insurance Co. Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Insured Party Sex

Male Female

Insured Party Address

City / State / Zip

Phone / Soc. Sec. #

Policy I.D. Number

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 additional 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 medication or antibiotic 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

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

Anesthetic Problems

Yes No

Is this 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 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 permit the office to communicate with me via text message on my cell phone.

Yes No

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

Office Financial Payment Policy

Please read the following to understand our office payment policy.1

1. The patient or guardian is responsible for all charges incurred at this office and will be required to pay their estimated portion the day of the surgery or 50% of the charges one week before implant or bone grafting surgery. The remaining balance is due on the day of the surgery.

2. As a courtesy to you, we will contact your insurance for benefits, eligibility and prepare and file your insurance claim to the best of our ability. Most insurance carriers pay claims within 30‐60 days. If you have not been notified of payment by the sixth week, you should contact your insurance carrier. Please remember, IN THE EVENT YOUR INSURANCE DOES NOT PAY FOR THE SERVICES PROVIDED, YOU ARE FULLY RESPONSIBLE FOR THE CHARGES DUE TO OUR OFFICE. The insurance companies do not allow us to set their premium rates and we in turn do not permit them to arbitrarily set our fee schedule. IT IS YOUR RESPONSIBILITY TO KNOW YOUR INSURANCE BENEFITS SUCH AS DEDUCTIBLES, LIMITATIONS, PREAUTHOURIZATIONS, FREQUENCY LIMITS, NON‐DUPLICATING CLAUSE, INSURANCE REQUIREMENTS SUCH AS PREAUTHORIZATIONS, ETC.

3. If you are a member of a PPO/HMO that the doctor is contracted with, we will abide by all rules of our contract. If the doctor is NOT a member of your health plan, you will be responsible for all non‐covered amounts. IT IS YOUR RESPONSIBILITY TO KNOW WHO YOUR INSURANCE PROVIDERS ARE AND BE AWARE OF YOUR INSURANCE BENEFITS.

4. The doctor is NOT a Medicare Provider. This means that we will NOT file for benefits and do NOT accept assignment of benefits.

5. Please understand that the estimate you were given of your portion IS ONLY AN ESTIMATE. Regardless of any reason for denial or nonpayment by your carrier, any unpaid balance will become the patient’s full responsibility and is due and payable 90 days from the date of billing. We do not know each insurance carrier’s individual rules and regulations. If you wish to determine your benefits or provisions of your insurance carrier, YOU should contact your employer, union or insurance carrier to obtain precise information about your coverage. VERBAL AND/OR WRITTEN APPROVAL FROM YOUR INSURANCE COMPANY DOES NOT GUARANTEE PAYMENT.

6. We accept cash, debit card, check (with driver’s license), money order, American Express, Visa, MasterCard and Discover and Care Credit . ALL CHECKS NOT HONORED BY YOUR BANK WILL BE ELECTRONICALLY COLLECTED FROM YOUR ACCOUNTS AND YOU WILL BE CHARGED $25.00 BY OUR OFFICE.

My signature below certifies that I have read and, if requested, received one copy of this policy. I have also asked any questions I have regarding cost prior to services being rendered.

Patient or Responsible Party’s Name

Patient or Responsible Party’s Signature

Click to Sign

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

Patient Consent Form

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

The patient understands that:
• Protected health information may be disclosed or used for treatment, payment or health care operations.
• The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.
• The Practice reserves the right to change the Notice of Privacy Policies.
• The patient has the right to restrict the uses of their information but the Practice does not have to agree to those restrictions.
• The patient may revoke this Consent, in writing, at any time and all future disclosures will then cease.
• The Practice may condition treatment upon the execution of this Consent.
• List family/friend we are allowed to disclose your medication information to:

Signed

Click to Sign

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

Patient / Guardian Name

Relationship

INFORMED CONSENT FOR CONTROLLED SUBSTANCE THERAPY FOR PAIN

Please review the information listed here and initial each item.

In Nevada, per Assembly Bill 474, prescribers must inform their patients of information regarding the treatment of pain with the use if a controlled substance. It is important that you review the following information carefully to make an informed choice about the medication(s) prescribed.

I understand that I am being prescribed medications, including controlled substance for the treatment of pain.

Initial

Click to Sign

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

I understand that all pain medications, including controlled substances, have different benefits and risk in the treatment of my symptoms.

Initial

Click to Sign

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

I understand that prescribed controlled substances can carry serious risk of addiction and overdose, especially with prolonged use.

Initial

Click to Sign

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

I understand that I am not to use the controlled substance prescribed to me in conjunction with drugs, alcohol or other medications (unless otherwise directed by my prescriber).

Initial

Click to Sign

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

I understand that when I take controlled substances, I may experience certain reactions or side effects that could be dangerous, including but not limited to, sleepiness or sedation, constipation, nausea, itching, allergic reactions, problems with thinking clearly, slowing of my reactions, or slowing of my breathing.

Initial

Click to Sign

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

I understand that when I take controlled substances, it may not be safe for me to drive a car, operate machinery, or take care of other people. If I feel sedated, confused or otherwise impaired by these medications, I understand that I should not do things that would put myself or other people at risk for being injured.

Initial

Click to Sign

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

I understand that when I take controlled substances, I may become physically dependent on them, meaning my body will become accustomed to taking the medications daily, and I would experience withdrawal sickness if I stop them or cut back on them too quickly. Withdrawal symptoms may include abdominal pain, nausea, vomiting, diarrhea, sweating, body aches, muscle cramps, runny nose, anxiety, and sleep problems.

Initial

Click to Sign

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

I understand that I may become addicted to controlled substances and require addiction treatment if I cannot control how I am using them, or if I continue to use them for a prolonged period of time.

Initial

Click to Sign

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

I understand that anyone can develop an addiction to pain medications, but people who have had problems with mental illness or with controlling drug or alcohol use in the past or who have a parent or sibling who has had a drug or alcohol abuse problems are at higher risk.

Initial

Click to Sign

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

I understand that I must store prescriptions in a secure place out of reach of children, other family members and others and/or use a locked medicine cabinet. To safely dispose of unused medications, I can return the unused medications in the bottle to a local pharmacy, a local drug take -back day, or a local police or sheriff substation in my community, or I may safely dispose of them by dissolving them in a Dettera pouch. I understand that I am not to dispose of unused medications into the toilet or sink.

Initial

Click to Sign

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

I understand that my doctor cannot refill my controlled medication via telephone and, therefore, any request for refills will require another office visit with a possible assessment or consultation. I understand that my doctor may decline to refill my prescription if he believes it to be medically unnecessary or harmful to my well-being. I understand that I am being prescribed a controlled substance for a short duration.

Initial

Click to Sign

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

I understand that due to risk of possible overdose from use of controlled substances, the opioid overdose antidote naloxone (Narcan) is now available without a prescription. I may obtain naloxone (Narcan) from a pharmacist.

Initial

Click to Sign

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

For Women: It is my responsibility to tell my prescriber immediately if I think I am pregnant or if I am thinking of about getting pregnant. I understand the risk to a fetus of chronic exposure to controlled substances during pregnancy, including the risk of fetal dependency on the controlled substance, neonatal abstinence syndrome, neurologic and heart problems in the baby, prematurity and fetal or neonatal death.

Initial

Click to Sign

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

Informed Consent:
I understand each of the statements written here and by signing, I give my consent for treatment of my pain condition with medication including controlled substances. I understand that I will have the opportunity to ask any questions that I may have regarding my treatment of pain with medications, including controlled substances.

Patient Name

Patient/Guardian Signature

Click to Sign

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

Main Header

Demographic Information

Patient information

In Case of Emergency

Who will be responsible for your account

Spouse or other guarantor information (if different from above)

Insurance Information

Primary Dental Insurance Company

Secondary Dental Insurance Company

Health History

Health History

Have you had or do you currently have...

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 medication or antibiotic you are allergic to

Conclusion

Conclusion

Is there a FAMILY history of

Is this related to an accident?

Verification

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Office Financial Payment Policy

Office Financial Payment Policy

Click to Sign

Patient Consent Form

Patient Consent Form

Click to Sign

Informed Consent for Controled Substance Therapy for Pain

INFORMED CONSENT FOR CONTROLLED SUBSTANCE THERAPY FOR PAIN

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Click to Sign

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.