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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. #

Tel. / Driver's License Number

Address

City / State / Zip

Employer / Business

Spouse or other guarantor information (if different from above)

Name

Relation / Tel.

Birth Date / Soc. Sec. #

Address

City / State / Zip

Employer / Business

Insurance Information

Marital status

Married Divorced Widow Single Legally Separated

Employed

Full Time Part Time Retired Not

Primary Dental Insurance Co...

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Insurance Co. Name

Policy I.D. Number

Insurance Co. Address

City / State / Zip

Phone Number

Group

Insured Party

Relation / Birth Date

Insured Party Sex

Male Female

Insured Party Address

City / State / Zip

Phone / SSN#

Secondary Dental Insurance Co...

Employer / Business

Business Address

City / State / Zip

Phone Number

Plan Name

Insurance Co. Name

Policy I.D. Number

Insurance Co. Address

City / State / Zip

Phone Number

Group

Insured Party

Relation / Birth Date

Insured Party Sex

Male Female

Insured Party Address

City / State / Zip

Phone / SSN#

Dental Information

Reason for today’s visit

Are you in pain

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

Please list any other medication or antibiotic you are allergic to:

Women only

Women 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.

Is there a possibility of pregnancy?

Yes No

Expected delivery date:

Are you nursing?

Yes No

Are you taking birth control pills

Yes No

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.

I hereby authorize Jacob D. Hager, DDS, MS, Blaire A. Bowers, DDS, MS, and Lauren E. Klaus, DDS, MS to obtain verbal or written information from my physician to aid in a more complete medical history if needed.

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. Any benefit resulting from an insurance plan will be utilized as a means of reimbursement the costs associated with rendered treatment are the responsibility of the patient.

Signature of patient (Parent or Guardian if Minor)

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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)

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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)

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

Authorization for Release of Private Health Information

I authorize the Periodontal Implant Center to release and share my health information with the following individuals / entities:

1. My general dentist
2. My dental insurance company
3. My medical insurance company (if applicable)
4. Any other medical offices and/or providers that need consulted regarding my dental and periodontal treatment needs
5. Other (Please list all other individuals / entities that we are authorized to share your health information. For any individual over age 18, this should include your parent(s) and spouse if they are to be involved in any part of your treatment planning, decisions and payment process. )

Name

Relationship

Name

Relationship

Name

Relationship

Name

Relationship

I authorize the use any photos taken during my examination and/or treatment to be used for treatment coordination with other medical providers and/or educational purposes.

Yes No

I have read and understand this form. I speak and understand English and voluntarily authorize the disclosure of my health information as described above in this form.

Patient Signature

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

Legal Representative / Guarding

Relationship to Patient

Legal Representative / Guarding (Signature)

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

Spouse or other guarantor information (if different from above)

Insurance Information

Insurance Information

Primary Dental Insurance Co...

Secondary Dental Insurance Co...

Dental Information

Dental Information

Please indicate any of the following problems by checking off the corresponding box

Medical History

Medical History

Do you have, or have you had, any of the following diseases, medical conditions, or procedures

Are you now taking

Please list any medications you are currently taking

Are you allergic or had a reaction to

Please list any other medication or antibiotic you are allergic to:

Women only

Conclusion

Verification

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Click to Sign

Click to Sign

Click to Sign

Authorization for Release

Authorization for Release of Private Health Information

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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

Insurance Information

Primary Dental Insurance Co...

Secondary Dental Insurance Co...

Dental Information

Dental Information

Please indicate any of the following problems by checking off the corresponding box

Medical History

Medical History

Do you have, or have you had, any of the following diseases, medical conditions, or procedures

Are you now taking

Please list any medications you are currently taking

Are you allergic or had a reaction to

Please list any other medication or antibiotic you are allergic to:

Women only

Conclusion

Verification

Click to Sign

Click to Sign

Click to Sign

Click to Sign

Authorization for Release

Authorization for Release of Private Health Information

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.

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