SCHOOL INFO

PRIMARY DENTAL INSURANCE COMPANY

INSURED PARTY

SECONDARY DENTAL INSURANCE COMPANY

INSURED PARTY

PRIMARY MEDICAL INSURANCE COMPANY INFORMATION

INSURED PARTY

SECONDARY MEDICAL INSURANCE COMPANY

INSURED PARTY

HEALTH HISTORY

Medication- Are you now taking or have taken..

Allergies - Are you allergic to , or had any reactions to ..

Is there a FAMILY HISTORY of:

IN CASE OF EMERGENCY, CONTACT:

IS THIS VISIT RELATED TO AN ACCIDENT?

 

THIS SECTION IS FOR WOMAN ONLY, SELECT SKIP FOR MEN TO CONTINUE BELOW

WOMEN NOTE: Antibiotics (such as penicillin)may alter effectiveness of birth control pills, consult your physician/ gynecologist for assistance regarding additonal methods of birth control.

I certify i have read and understand the questions above. I acknowledge that my questions, if any, about the enquires set forth above has been answered to my satisfaction. I will not hold my surgeon or any other member of his/her staff, responsible for any errors or ommisions in completion of this form.

FEES AND PAYMENTS

We make every effort to keep down the cost of your surgical 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 informationon 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 for your insurance company. You will be responsible for all collections costs, attorneys fees, and court cost.

AUTHORIZATION

I authorize my surgeon and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatement planning. Furthermore, I authorize the taking of all X-rays required as a necessary part of this examination. In addition, if medically necessary , I authorize the release of any information acquired in the course of any examination and treatement.

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 the notice.