Grand Junction Oral Surgery and Dental Implants

Main Header

Joseph R. Funderburk, DDS
Diplomate, American Board of Oral & Maxillofacial Surgery

Person Responsible For Payment

Name

Relationship / SS#

Date of Birth / Age

Mailing address

(Click here to add text)

Home phone # / Work phone # / Cell phone #

Employer / How long?

Insurance Coverage - Please bring all insurance cards as well as completing information below.

Dental Insurance

Company / Phone #

Claims Address

Employee

ID# / Date of Birth

Employer / Group #

Medical Insurance

Company / Phone #

Claims Address

Employee

ID# / Date of Birth

Employer / Group #

I hereby authorize payment directly to the dentist of the group insurance benefits otherwise payable to me.

Signature

Click to Sign

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

Health and Medical History

Please answer each question below. Complete and accurate information is necessary to insure that appropriate care is provided. Your answers are for our records only. All information will be held in the strictest confidence. Thank you for your time and completeness.

Sex / Height / Weight

Do you Smoke? How much? For how long?

Do you drink alcohol? How much?

Are you now under the care of a physician? For what condition?

Have you ever been hospitalized for illness? Surgery?

For what? (Please list with dates)

Have you had a general anesthetic in a hospital?

Were there any problems with the anesthetic?

Has any family member had an adverse reaction to anesthesia?

Do you take ANY drugs (prescription, herbal, holistic, non-prescription or over-the-counter)? Please list names and dosages

Do you take ANY drugs (prescription, herbal, holistic, non-prescription or over-the-counter)?

Medication #1

Medication #2

Medication #3

Medication #4

Medication #5

Medication #6

Medication #7

Medication #8

Have you stopped taking prescription medication without your physician's knowledge?

Women Only

Surgery and anesthesia during early pregnancy may be harmful to the unborn child. If you are to have surgery with this office would you like to speak with a physician prior to the procedure?

Date of last menstrual period?

Are you or may you be pregnant?

Are you trying to become pregnant?

Are you taking birth control pills?

Are you breast feeding an infant?

Conclusion

Signature of patient (or parent/guardian if underage)

Click to Sign

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

Name of person who filled out this form (if different from patient)

Financial Policy

Grand junction Oral Surgery welcomes you to our practice of Oral and Maxillofacial Surgery. We would appreciate your completing the information and health questionnaire to help us in our diagnosis and treatment. Our policy is to openly discuss our diagnosis and treatment recommendations with you. We encourage you to ask any questions you may have.

PAYMENT POLICY-We encourage a frank discussion of fees and billing procedures and prefer to answer any questions or concerns at the beginning of treatment. Payment in full is due when services are rendered unless specific arrangements are made in advance. The amount of payment may be determined in advance.

INSURANCE-Dental benefit plans are dramatically different than medical plans. Dental plans are designed to be PAYMENT ASSISTANCE plans. Your treatment will be determined by your dental needs and your general health, not by your dental benefit plan. If possible, we will verify your benefits. The difference between your estimated insurance benefit and your treatment fee will be the amount you will be expected to pay in advance. This office will file your insurance for you at no cost, if you desire, but payment of your account is your direct responsibility. This office does not take responsibility for negotiating disputed claims. Questions should be directed to your insurance company, rather than this office.

If there are no insurance benefits, the expected payment will be l 00% of the treatment fee or will be determined by prior arrangement. We accept Visa, MasterCard, American Express, and Discover.

FINANCING--We offer monthly payments through CareCredit, a medical credit card. It is interest-free for a 12-month period. For longer term financing, interest will be charged. It takes only a few minutes to apply for CareCredit over the phone, 1-800-365-8295, or on-line at www.carecredit.com.

INTEREST--All account balances remaining over 90 days, will be charged 1.5% monthly interest (18% APR).

COLLECTIONS--If this account is sent to collections, you agree that in addition to any amount left owing to Grand Junction Oral Surgery, you will be responsible for court costs and reasonable attorneys'frees, with or without suit, incurred in collecting any past due balance, and a collection fee if my account is assigned to a collection agency.

Once again, we are happy to have the opportunity to care for you and welcome your calls if you have questions or concerns.

RESPONSIBLE PARTY SIGNATURE

Click to Sign

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

Acknowledgement of Receipt of Notice of Privacy Practices & PDMP

I have received a copy of this office's Notice of Privacy Practices and notification that filling a prescription for narcotic, sedative, or controlled drugs will cause my name to be entered into a secure Colorado State database, (PDMP).

Name

Signature

Click to Sign

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

truForm by PBHS

Main Header

Patient Information

Patient Information

Responsible Party

Person Responsible For Payment

Insurance Coverage

Insurance Coverage - Please bring all insurance cards as well as completing information below.

Click to Sign

Health History

Health and Medical History

Do you take ANY drugs (prescription, herbal, holistic, non-prescription or over-the-counter)? Please list names and dosages

Medical History

Do you have or have you ever had:

Medical History Continued

Women Only

Conclusion

Conclusion

Click to Sign

Payment Policy

Financial Policy

Click to Sign

Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices & PDMP

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.

Main Header

Patient Information

Patient Information

Responsible Party

Person Responsible For Payment

Insurance Coverage

Insurance Coverage - Please bring all insurance cards as well as completing information below.

Click to Sign

Health History

Health and Medical History

Do you take ANY drugs (prescription, herbal, holistic, non-prescription or over-the-counter)? Please list names and dosages

Medical History

Do you have or have you ever had:

Medical History Continued

Women Only

Conclusion

Conclusion

Click to Sign

Payment Policy

Financial Policy

Click to Sign

Privacy Practices

Acknowledgement of Receipt of Notice of Privacy Practices & PDMP

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.