Are you taking any of the following?
Are you allergic to, or had a reaction to any of the following:
Please check all that apply
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 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.
For your convenience, we accept cash, Certified Check/Personal Checks
$500.00 or less, Visa, MasterCard, American Express, Discover, Care Credit
and most insurance plans. Personal checks that are returned due to “insufficient
funds” are subject to a $50.00 service fee. We deliver the finest
care at the most reasonable cost to our patients, therefore payment is
due at the time services are rendered. All accounts over 90 days will be
considered past due. Patient agrees to pay additional charges of 18% of
1.5 monthly finance charges (or the maximum percentage allowed by law,
whichever is lower) of the invoiced amount per month for any payment received
by Reston Advanced Oral & Cosmetic Facial Surgery, and affiliates or
employees representing or d/b/a Reston Advanced Oral & Cosmetic Facial
Surgery more than 90 days from the date of invoice or bill for services.
In the event collection of patient’s account is referred to an attorney,
patient agrees to pay all expenses incurred by Reston Advanced Oral &
Cosmetic Facial Surgery, and affiliates or employees representing or d/b/a/
Reston Advanced Oral & Cosmetic Facial Surgery in effecting payment,
specifically including attorney’s fees of 33-1/3% of the principal
due and owing. If you have questions regarding your account, please contact
us at (571) 595-3223. Many times, a simple telephone call will clear any
Please remember you are fully responsible for all fees charged by this
office regardless of your insurance coverage. We will send you a monthly
statement. We ask that you also realize that we do not work for an insurance
company. Rather we work 100% for our patients. We feel that insurance can
be a great benefit for many patients and want you to know we will do everything
in our power to ensure you receive every benefit allotted in your insurance
contract. However; the treatment we recommend and the fees we charge will
always be based on your individual needs, not your insurance coverage.
If you need to cancel or reschedule your appointment, please call us 48
hours in advance. If you fail to do so, or are not present at your scheduled
appointment, there will be a $500.00 charge.
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.
As a patient, please be advised that in accordance with Section 32.1-45.1
of the Code of Virginia, 1950, as amended, that if the provision of health
care services to the patient exposes any person employed by or under the
direction and control of this facility or any other healthcare provider,
to the patient's body fluids in a manner which may transmit immunodeficiency
virus or HIV or Hepatitis B or C viruses, then the patient will be deemed
to have consented to testing for infection with HIV or Hepatitis B or C
viruses, and the release of such test results to the person(s) exposed.
Click on the hyperlink to obtain a copy:
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 any questions I may have regarding this Notice.
I authorize my surgeon and his/her 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 certify that I have read and understand the office policies regarding
All of my questions have been answered to my satisfaction.