This form is HIPAA compliant to ensure privacy.

Washington Oral Surgery

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New Patient Registration Form

Patient Information

Title:

Sex:
First Name:

Date of Birth:

Nickname:
Age:
(calculated after submit)
Middle Initial:
Social Security #:
Last Name:
 

 Email:

 
Street Address:
Home Tel. #:
City:
Work Tel. #:
State:
Ext.:
Zip:
Mobile Tel#:
Employer Name:
Occupation:
 
Dentist:
Dentist Phone #:
Referred By:
Physician:
For Doctor:
Physician Phone #:
Spouse Name:
 
Emergency Contact:
Home Tel. #:
 Relation:
Work Tel. #:
 
Marital Status:

Have you ever been a patient of our practice?

How were you referred to our office?



Referral Name :

Method of Personal Payment:

Are you a student? 
 School:
Preferred appointment time:
 

Account Responsibility/Insurance Card Holder

Who will be responsible for your account? (if patient is a minor)
 
Title:

Date of Birth:

First Name:

Social Security #:

Middle Initial:
Driver's License #:
Last Name: Home Tel. #
 

Street Address:

 Mobile Tel. #:

City:

Employer Name:

State:

Emp. Tel. #:

Zip:

(if other) Relation:


Spouse or Guarantor Info (if different from above)

Title:

Social Security #:

First Name:

Tel. #:

Middle Initial:

Mobile Tel#:

Last Name:

Employer Name:

 

Street Address:

Emp. Tel. #:

City:

Relation:

State:

 

Zip:


Primary Dental Insurance

Employer Name:

Group #:

Emp. Tel. #:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Tel. #:

SSN/ID/Contract #:

Insurance PO Box:    
Relationship to Patient:

Primary Medical Insurance

Employer Name:

Group #:

Emp. Tel. #:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Tel. #:

SSN/ID/Contract #:

Insurance PO Box:    
     Relationship to Patient:

Secondary Insurance

Type of Insurance:

Employer Name:

Group #:

Emp. Tel. #:

Subscriber Name:

Ins. Co. Name:

Subscriber Birthday:

Insurance Tel. #:

SSN/ID/Contract #:

Insurance PO Box:    
     Relationship to Patient:

General Health

Are you in relatively good health?
Height:
Weight:
Have there been any changes in your general health in the past year?
If yes, please explain:
Are you under the care of a physician?
Date of last visit:
For what are you being treated?
Have you had any illness, operation or been hospitalized in the past five years?
If yes, please explain:
Do you have injuries or inflamed areas, growths or sore spots in or around your mouth?
Where:
Do you have a heart valve replacement or vascular graft?
Where:
Is this visit related to an accident?
When was the accident?
Are there conditions that the doctor should be aware of?
Please List:
Do you wish to speak to the doctor privately regarding your conditions?

Conditions

High / Low blood pressureChest pain / angina
Heart Murmur / Mitral Valve ProlapseIrregular heartbeat
Cardiac pacemakerHeart surgery
StrokeHeart attack(s)
Blood transfusionSwollen ankles, arthritis, or joint disease
Chronic fatigue / night sweatsRheumatic fever
Damaged heart valvesProblems with the immune system
Sexually transmitted diseasesTumor or growth
X-Ray treatment / chemotherapyInfectious mononucleosis
Delay in healingMalignant hyperthermia
Immunodeficiency disease I smoke
Difficult breathing / other lung troubleBronchitis / chronic cough
Asthma / EmphysemaHay fever / sinus problems
TuberculosisI am on a diet
Thyroid troubleLow blood sugar
DiabetesStomach ulcers
Gallbladder troubleBlood disorder such as anemia
Bruise easilyBleeding tendency (abnormal bleeding)
Mental health problemsHistory of drug / alcohol abuse
Convulsions / epilepsyFainting spells
Kidney trouble / DialysisEye Disease / Glaucoma
Contact lensesHepatitis
Pain & clicking of jaws when eatingProsthetic Joint
Other Medical Issues not listed above

Medication & Allergies

Are you taking any kind of medicine, drugs, or pills?
Please list: (especially for Bone Density i.e. Bisphosphonates)
Have you ever taken diet pills?
Please list:

Are you allergic to or have you ever had an adverse reaction to local anesthetics?
Are you allergic to or have you ever had an adverse reaction to aspirin?
Are you allergic to or have you ever had an adverse reaction to latex?
Are you allergic to or have you ever had an adverse reaction to penicillin?
Are you allergic to or have you ever had an adverse reaction to other medications?
Please list all allergies and adverse reactions that you are aware of below:

Women Only

Is it possible that you are currently pregnant?
Are you nursing?
Are you currently taking birth control medicine?

Family History (please  check  all  that  apply)







Fees and Payments
We make every effort to keep down the cost of your oral 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 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 for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.


I certify that I have read and understand the above. 
I authorize the release of information necessary to process my claim. I hereby authorize to this doctor named of the benefits otherwise payable to me. 
Patient Acknowledgements
Basic Policy: Payment for services rendered is due in full at the time of service. Our office accepts cash, personal checks (with valid driver’s license), and credit cards (Master Card/Visa). There is a $25.00 returned check fee due and payable from you for each check returned to us by your bank. You will be responsible for any collection or legal fees deemed necessary to assure payment.

For Patients with Insurance: As a service to our patients, we will bill your insurance carrier, provided proper paperwork is provided to us. We will assist you in billing your secondary insurance carrier if applicable, and in researching unpaid claims. Every effort will be made to closely estimate your co-payments and deductibles which are due at the time of service, but the ultimate responsibility for any unpaid balance rests on you. Please understand that insurance is a contract between you and your insurance company. If an insurance carrier has not paid within 60 days of billing, any unpaid professional fees are due and payable in full from you.

Managed Care Participants: Some benefit plans require pre-authorization and specialist referral forms from your dentist or primary physician. Please provide the proper plan identification and forms necessary prior to your visit. All co-payments or patient out-of-pocket fees are due and payable at the time of service.

Surgery Fees: All co-payments, deductibles and payments for non-covered surgical procedures are due prior to your surgery. Prior authorization may be required by your insurance carrier.

Non-Covered Charges: Any charges not paid by your insurance carrier will require payment in full at the time services are provided or upon notice of insurance claim denial.

Follow-Up: Periodic postoperative office visits may or may not be covered under your insurance plan however, these may be required by the attending doctor to monitor your health.

Cancellation of Appointments: Our goal is to provide high quality of care at low cost to our patients and in fairness to other patients and the doctor, we require at least 24 hours notice when canceling an appointment. There is a 25.00 fee for missed appointments without 24 hour notification, which will be due and payable from you.

Please check one: I have paid my insurance deductible for the calendar year
YesNoI don't know

If your doctor or dentist has given you an x-ray and/or referral please remember to bring them with you along with your insurance card.

I have read, understand and agree to the above financial policy for payment of the professional fees. I am ultimately responsible for all fees for service provided to me.


I hereby acknowledge that I have been given the right to review the Notice of Privacy Practices for this office. (HIPAA) A copy of this notice can be viewed here.

I certify that I have read and understand the above.  I affirm that the information contained in this form and any additional information that I may furnish is true and correct to the best of my knowledge.  I understand the above information is necessary to provide me with dental care in a safe and efficient manner.  I will not hold Washington Oral Surgery  or the staff responsible for any errors or omissions that I have made in the completion of this form.

  
  Signature                                                                                                                 Date        

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