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In Case of Emergency

Please Contact:

Phone / Relation

Who will be responsible for your account

Who will be responsible for your account?

Self Spouse Father Mother Other

Name / Social Security Number

Birth Date / Age / S.S.#

Responsible Party Phone

Email / Driver's License

Address

City / State / Zip

Employer / Phone

General Insurance Information

Marital status

Married Divorced Widow Single Legally Separated

Employed

Full Time Part Time Retired Not

Are you a student?

Full-time Part-time Not a student

School Information

School Name

School Address

City / State / Zip

Primary Dental Insurance Information

Employer

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Sex

Male Female

Phone / S.S. #

Insured Party Address

City / State / Zip

Primary Medical Insurance Information

Employer

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Sex

Male Female

Phone / S.S. #

Insured Party Address

City / State / Zip

Do you have secondary dental or medical insurance?

Yes No

Secondary Dental Insurance Information

Employer

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Sex

Male Female

Phone / S.S. #

Insured Party Address

City / State / Zip

Secondary Medical Insurance Information

Employer

Business Address

City / State / Zip

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address

City / State / Zip

Phone Number

Group

Insured Party Name

Relation / Birth Date

Sex

Male Female

Phone / S.S. #

Insured Party Address

City / State / Zip

Is there a family history of:

Cancer

Diabetes

Heart disease

Anesthesia problems

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

Medication #20

Medication #21

Medication #22

Medication #23

Medication #24

Please list any other allergies:

Conclusion

Is there any condition concerning your health that the doctor should be told about?

Yes No

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

Yes No

Is this visit 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:-------------

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 do not participate with Medicare nor any medical insurance plans. We are participating with many but not all dental benefit plans. Participation is not a guarantee of payment. We will do our best to optimize your available benefits, to minimize your out-of-pocket expenses. However, we cannot guarantee what your insurance company will pay.

Expenses which may not be covered, but may be required for treatment are:

2D Panorex x-ray: Many insurance plans place frequency limitations on this service.

3D Cone beam computed tomography scan (CBCT): CBCT scanning technology will be utilized to acquire and reconstruct images of your jaw. Your insurance company requires this information to determine benefits for implant cases; we require this technology to ensure the best outcome.

Bone graft & other biologic materials: At the time of treatment, to help prepare the site for an implant or to improve a compromised site, the surgeon may determine a graft is necessary.

General anesthesia & Nitrous: Many insurance companies limit this based on the number of teeth removed and the level of complexity.

Implant & related parts: Many insurance companies have limitations on these procedures.

We will send a claim to your insurance company for these but cannot advise you whether or not it is a covered benefit under your plan. You will be responsible for payment of these procedures.

Please remember that insurance is considered a method of reimbursement for fees paid to the doctor and is not a substitute for payment. It is your responsibility to pay any deductible, co-insurance or any other balance not paid by your insurance company. You will be responsible for all collections 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)

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

AUTHORIZATION

I authorize my surgeon and their designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. In addition, if medically necessary, I authorize the release of any information acquired during my examination and treatment to my other doctors and/or insurance carrier.

I permit the office to communicate with me via email/voicemail/text messages and to leave messages concerning my appointments/treatment/and billing.

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

Signature of patient: (Parent or Guardian if Minor)

Click to Sign

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

AUTHORIZATION TO DISCUSS HEALTH INFORMATION WITH DESIGNATED PERSONS
*** NOTE: HEALTHCARE INFORMATION WILL NOT BE RELEASED TO ANY RELATIVE(S) (SPOUSE, MOTHER, FATHER, SISTER, BROTHER, ETC),
FRIEND(S) OTHER PERSON(S) UNLESS SPECIFICALLY LISTED AND AUTHORIZED BY THE PATIENT BELOW.

For this authorization, “My Health Information” means any and all information relating to my course of examination, test results, surgical treatments and other treatment. I authorize Dr. Tebyanian DMD MD, PA and his staff to discuss My Health Information, general information and inquires, arranging appointments, identifying medications, discussing billing and payment and any other related matters with:

Name

Relationship/Phone

Name

Relationship/Phone

Name

Relationship/Phone

I understand this authorization is voluntary. My treatment will not be impacted no matter if I sign this authorization or not. If I do not sign this authorization, Dr. Tebyanian DMD MD PA, and his staff will not disclose my health information to anyone other than to me. This authorization is valid until I revoke the authorization in writing. I understand that once My Health Information is disclosed as requested, it may no longer be protected by federal and/or state privacy laws and could possibly be re-disclosed by the person receiving it.

I hearby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me and 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

Main Header

Demographic Information

Patient information

In Case of Emergency

Who will be responsible for your account

Insurance Information

General Insurance Information

School Information

Primary Dental Insurance Information

Primary Medical Insurance Information

Secondary Dental Insurance Information

Secondary Medical Insurance Information

Health History

Health History

Health History Part 2

Have you ever had or do you currently have...

Have you ever had or do you currently have...

Is there a family history of:

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:

Column2

Conclusion

Conclusion

Is this visit related to an accident?

Verification

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Main Header

Demographic Information

Patient information

In Case of Emergency

Who will be responsible for your account

Insurance Information

General Insurance Information

School Information

Primary Dental Insurance Information

Primary Medical Insurance Information

Secondary Dental Insurance Information

Secondary Medical Insurance Information

Health History

Health History

Health History Part 2

Have you ever had or do you currently have...

Have you ever had or do you currently have...

Is there a family history of:

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:

Column2

Conclusion

Conclusion

Is this visit related to an accident?

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.

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