Community Oral and Maxillofacial Surgery

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Emergency Contact

Emergency Contact Name

Phone

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.#

Address

City / State / Zip

Email / Driver's License

Responsible Party Phone

Patient Information Continued

Is the patient a minor?

Yes No

Name of legal guardian

If not listed above, please provide legal guardian’s phone number & address

Phone

Address

City/State/Zip

Does the patient have a decision-making capacity?

Yes No

(If no, provide name & phone number of the patient’s legal representative or health care power of attorney who we can contact to obtain consent for treatment)

Name

Phone

Does the patient require any special accommodations including language interpretation

Yes No

(including American sign language), accommodations for service animals, accessibility, …etc.)?

FINANCIAL POLICY/ FEES AND PAYMENTS

Accepted forms of payment:
For your convenience, we accept payment in the form of check, debit card, credit card (Visa, MasterCard, Discover, or American Express). We also accept Apple pay and Samsung pay. All payments for any oral and maxillofacial surgery services are due before or at the time of service.

Insurance policy:
To help maximize benefits available to you from your insurance plan or benefits carrier, Community Oral and Maxillofacial Surgery is committed to submitting claims and filing any necessary supplementary material to your dental benefits carrier and/or medical insurance provider for services rendered to you. Every attempt to successfully submit claims on your behalf will be made by our team. Please complete the insurance section above to assist us in this effort and notify us immediately of any changes in your insurance coverage.

Please note that benefits payable for procedures vary depending on the coverage provided by your plan. Our team may be able to provide you with an estimate of this coverage amount or percentage. If you have concerns regarding your coverage, we encourage you to contact your insurance carrier directly. Community Oral and Maxillofacial Surgery makes no guarantee of coverage or payment by a third party.

Please note that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some insurance companies or benefits carriers pay a fixed allowance 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 that is not paid for by your insurance company. These payments are due before or at the time of service.

Deposits and Cancelled Appointments:
Procedures that require an advanced order of materials or medications may require a deposit to be collected at the time that your appointment is scheduled. If any of these orders are custom made to you, we will not be able to return them and they will be wasted. Payment for these materials and medications will be collected at the time your appointment is scheduled. Failure to show up for the appointment or a cancellation will result in the forfeiture of all or part of the deposit that you made.

We require at least 48 hours’ notice for appointment cancellations. Failure to show for the appointment may result in a cancellation fee.

By signing below:
- I acknowledge that I have read and understand the financial policies listed above, and
- I authorize the release of the necessary information required by my insurance/benefits provider to process my dental/medical insurance claims, and
- I authorize insurance and benefits payments to be made directly to Community Oral and Maxillofacial Surgery

Patient Signature (Parent, Legal Guardian, Healthcare Power of Attorney)

Click to Sign

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

IF PATIENT IS NON-DECISIONAL OR IS A MINOR

Form signed by

Relationship to Patient

Acknowledgment of Receipt of Notice of Privacy Practices

I hereby acknowledge that I have reviewed a copy of this office's Notice of Privacy Practices. I give my permission to discuss this account to the following:

Name 1.

Name 2.

Name 3.

Patient Signature
(Parent, Legal Guardian, Healthcare Power of Attorney)

Signature label

Click to Sign

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

Any other medical conditions not listed above?

Yes No

Female Patients

Are you pregnant?

Yes No

Name of OB provider / Phone

Are you nursing?

Yes No

If yes, how old is your child?

How much do they weigh?

Are you taking any birth control pills?

Yes No

Please note that antibiotics (such as Penicillin) may alter the effectiveness of birth control pills. Consult with your physician/OB/GYN about additional methods of birth control.

ALLERGIES/REACTIONS Please list any medications that you are allergic to:

Medication / Reaction

Please list any foods or drinks that you are allergic to (include allergies to eggs and/or soy):

Food/Drink / Reaction

Allergies continued...

Do you have an allergy to Latex?

Yes No

Please list other allergies here:

Are there any other medical conditions or concerns that you would like to discuss with the team?

Yes No

Do you wish to speak to the doctor privately about anything?

Yes No

FORM COMPLETION

I understand the importance of a truthful and complete health history to assist my doctor in providing coordinated care. To the best of my knowledge, the above information is complete and correct.

Patient Signature (Parent, Legal Guardian, Healthcare Power of Attorney)

Click to Sign

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

IF PATIENT IS NON-DECISIONAL OR IS A MINOR

Form signed by

Relationship to Patient

truForm by PBHS

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Demographic Information

Patient information

Emergency Contact

Who will be responsible for your account

Patient Information Continued

Insurance Information

PRIMARY DENTAL INSURANCE COMPANY

SECONDARY DENTAL INSURANCE COMPANY (if applicable)

PRIMARY MEDICAL INSURANCE COMPANY

SECONDARY MEDICAL INSURANCE COMPANY

FINANCIAL POLICY/ FEES AND PAYMENTS

FINANCIAL POLICY/ FEES AND PAYMENTS

Click to Sign

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Acknowledgment of Receipt of Notice of Privacy Practices

Click to Sign

Health History

Health History

Medications / Allergies

MEDICATIONS

Health History Part 2

Do you have, or have you ever had, any of the following conditions:

Female Patients

Allergies/ Reactions

ALLERGIES/REACTIONS Please list any medications that you are allergic to:

Please list any foods or drinks that you are allergic to (include allergies to eggs and/or soy):

Allergies continued...

Health History Continued...

Conclusion

FAMILY HISTORY Does anyone in your family have a history of:

FORM COMPLETION

Click to Sign

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Main Header

Demographic Information

Patient information

Emergency Contact

Who will be responsible for your account

Patient Information Continued

Insurance Information

PRIMARY DENTAL INSURANCE COMPANY

SECONDARY DENTAL INSURANCE COMPANY (if applicable)

PRIMARY MEDICAL INSURANCE COMPANY

SECONDARY MEDICAL INSURANCE COMPANY

FINANCIAL POLICY/ FEES AND PAYMENTS

FINANCIAL POLICY/ FEES AND PAYMENTS

Click to Sign

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Acknowledgment of Receipt of Notice of Privacy Practices

Click to Sign

Health History

Health History

Medications / Allergies

MEDICATIONS

Health History Part 2

Do you have, or have you ever had, any of the following conditions:

Female Patients

Allergies/ Reactions

ALLERGIES/REACTIONS Please list any medications that you are allergic to:

Please list any foods or drinks that you are allergic to (include allergies to eggs and/or soy):

Allergies continued...

Health History Continued...

Conclusion

FAMILY HISTORY Does anyone in your family have a history of:

FORM COMPLETION

Click to Sign

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Please rotate your device to portrait orientation to begin.

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