Dr. George W. May, Jr., DMD and Dr. Misty Goff Roberts, DMD

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Patient information

Prefix

Mr. Mrs. Ms. Dr.

Sex

Male Female

Name

Birth Date / Age / Soc. Sec. #

Mailing Address

City / State / Zip

Phone Number

Email Address

Referred By

Driver's License Number

Employer / Business Phone

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 / Age / S.S.#

Responsible Party Phone

Email / Driver's License

Address

City / State / Zip

Employer / Business Phone

PRIMARY MEDICAL INSURANCE COMPANY

Insurance Company

Ins. Claims Address

City/State/Zip

Ins. Co. Phone

ID / Group #

Policy Holder’s Name

Relationship to Patient

Policy Holder’s SS #

Policy Holder’s Employer

Policy Holder’s Birthdate

Policy Holder’s Phone

PRIMARY DENTAL INSURANCE COMPANY

Insurance Company

Ins. Claims Address

City/State/Zip

Ins. Co. Phone

ID / Group #

Policy Holder’s Name

Relationship to Patient

Policy Holder’s SS #

Policy Holder’s Employer

Policy Holder’s Birthdate

Policy Holder’s Phone

SECONDARY MEDICAL INSURANCE COMPANY

Insurance Company

Ins. Claims Address

City/State/Zip

Ins. Co. Phone

ID / Group #

Policy Holder’s Name

Relationship to Patient

Policy Holder’s SS #

Policy Holder’s Employer

Policy Holder’s Birthdate

Policy Holder’s Phone

SECONDARY DENTAL INSURANCE COMPANY

Insurance Claims Address

Ins. Claims Address

City/State/Zip

Ins. Co. Phone

ID / Group #

Policy Holder’s Name

Relationship to Patient

Policy Holder’s SS #

Policy Holder’s Employer

Policy Holder’s Birthdate

Policy Holder’s Phone

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

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

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

POLICY FOR APPOINTMENTS INVOLVING SURGERY

The day of your appointment, if you are having surgery, there may be driving and / or eating restrictions. The office will review this information with you prior to your procedure. I acknowledge that I have read and I understand the policy above.

Signature of patient (Parent or Guardian if Minor)

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

truForm by PBHS

Dr. George W. May, Jr., DMD and Dr. Misty Goff Roberts, DMD

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Demographic Information

Patient information

In Case of Emergency

Who will be responsible for your account

Insurance Information

PRIMARY MEDICAL INSURANCE COMPANY

PRIMARY DENTAL INSURANCE COMPANY

SECONDARY MEDICAL INSURANCE COMPANY

SECONDARY DENTAL INSURANCE COMPANY

Health History

Health History

Health History Part 2

HAVE YOU EVER HAD, OR DO YOU CURRENTLY HAVE:

This Section Is for Women Only

Medications / Allergies

Medications (Are you now taking...)

Please list any medications you are currently taking

Are you allergic to or had a reaction to:

Conclusion

Verification

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Dr. George W. May, Jr., DMD and Dr. Misty Goff Roberts, DMD

Main Header

Demographic Information

Patient information

In Case of Emergency

Who will be responsible for your account

Insurance Information

PRIMARY MEDICAL INSURANCE COMPANY

PRIMARY DENTAL INSURANCE COMPANY

SECONDARY MEDICAL INSURANCE COMPANY

SECONDARY DENTAL INSURANCE COMPANY

Health History

Health History

Health History Part 2

HAVE YOU EVER HAD, OR DO YOU CURRENTLY HAVE:

This Section Is for Women Only

Medications / Allergies

Medications (Are you now taking...)

Please list any medications you are currently taking

Are you allergic to or had a reaction to:

Conclusion

Verification

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.

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