Are you taking any of the following?
Are you allergic to, or had a reaction to any of the following:
WARNING: Antibiotics (such as penicillin) may alter the effectiveness
of birth control pills. Consult your physician for assistance regarding
additional methods of birth control.
I have read and understand the above. I understand the importance of a
truthful and complete Health History to assist in providing the best care
possible. I hereby acknowledge that all information above is correct.
We make every effort to keep down the cost of your oral surgical care.
You can help by paying on 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 at the top of the 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 other 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. Any account over 90 days will be charged a 1-1/2% finance charge
monthly with an annual rate of 18%, in addition to any collection agency
fees and/or attorney fees and court costs incurred in the collection of
This signature on file is my authorization for the release of information
necessary to process my claim. I hereby authorize payment directly to the
dentist name of the insurance benefits otherwise payable to me.
Click on the hyperlink to obtain a copy:
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: