Although oral surgeons primarily treat the area in and around your mouth,
your mouth is a part of your entire body. Health problems that you may
have, or medications that you may be taking, could have an important interrelationship
with the care that you will be receiving. Thank you for answering the following
questions. Your answers are for our records only and will be considered
confidential.
WARNING: Antibiotics (such as penicillin) may alter the effectiveness
of birth control pills. Consult your physician for assistance regarding
additional methods of birth control.
Are you taking, or have you ever taken, bone density meds or bisphosphonates
such as Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Xgeva, Prolia, or
Reclast in the past 12 years?
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 surgeon, or any other member
his/her staff, responsible for any errors or omissions that I have made
in the completion of this form.
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 by your insurance company.
You will be responsible for all collection costs, attorney fees and court
costs.
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.
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 questions I may have regarding this Notice.
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
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.