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PATIENT REGISTRATION INFORMATION

Required
Required
Required

Emergency Contact


Insurance Information

Primary Dental Insurance Company

Primary Medical Insurance Company


Health History

Please answer the following questions carefully and honestly. The information you provide is confidential and will assist us in providing you the best possible care. Please explain any YES answers.


Medications


Allergies/ Reactions


For Women Only

WARNING: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician for assistance regarding additional methods of birth control.


Have you had or do you currently have the following:


Form Completion

I honestly and accurately attest to the above medical history and authorize the release of this medical information, as necessary, for my treatment.

Required

If Patient is a Minor


ACKNOWLEDGMENT OF ANESTHESIA & MEDICATION USE IN YOUR CARE

I acknowledge that certain medications that may be prescribed to me by my doctor at Northeast Oral Surgery and Dental Implant Center may alter my state of mental awareness and decision making. Depending on the type of anesthetic given, I understand the importance of adhering to the following:

• Refrain from driving a car.
• Refrain from operating machinery of any kind.
• Refrain from making important personal or business decisions.
• Refrain from drinking alcohol of any kind.
• Refrain from taking sedatives (prescribed by another doctor or over-the-counter).
• Refrain from taking different medications at the same time. To avoid nausea, wait 30-60 minutes between taking each medication.

PATIENT FINANCIAL POLICY

Please initial your understanding and acknowledgment of this policy below.

By initialing below, I agree to the terms of the Patient Financial Policy document.

Click on the hyperlink to obtain a copy:

ACKNOWLEDGMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

Click on the hyperlink to obtain a copy:

The Health Insurance Portability and Accountability Act of 1996 establishes an individual’s right to access and receive copies for their Protected Health Information (PHI). Additionally, this act provides for an individual to designate person(s) they are associated with, such as parent, guardian, spouse, child, etc. (this is in addition to their personal physician or dentist) to have access to their PHI. 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:

INSURANCE REFERRAL WAIVER

Please initial your understanding and acknowledgment of this policy below.

I have been informed by Northeast Oral Surgery and Dental Implant Center that based on the rules and regulations of my insurance policy; it is my responsibility to have a referral in place with my medical insurance company from my primary care physician.

I understand that if I do not have a referral in place, claims submitted by Northeast Oral Surgery and Dental Implant Center may not be paid and will be my financial responsibility.

Required
Required

If Patient is a Minor

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