DSNForms

Great Basin Oral & Facial Surgery - GBOFS - Patient Form

Patient information

*Prefix

*First Name

Middle Name

*Last Name

*Date of birth

Social Security Number

Email

*Gender

Street Address 1

Street Address 2

Apt.

City

State

Zip

Primary Phone

Alternate Phone (Mobile, work, or home)

Have you ever been a patient of our practice?

Has a family member ever been a patient of our practice?

Dentist Name

First Name

Last Name

Orthodontist Name

First Name

Last Name

Medical Doctor Name

First Name

Last Name

Who were you referred by?

First Name

Last Name

Preferred Pharmacy Name

Preferred Pharmacy Phone

Upload your Driver's license

Maximum allowed size : 25MB

Upload your insurance card

Maximum allowed size : 25MB

Upload the back your insurance card

Maximum allowed size : 25MB
Nearest relative not living with you

First Name

Last Name

Relative Phone

Personal Payment Type

Who will be responsible for your account?

Guarantor Information

First Name

Last Name

Relative Phone

Date of birth

Social Security Number

Street Address 1

Street Address 2

Apt.

City

State

Zip

Employer/Business Name

Home Phone

Business Phone

Insurance information

General Insurance information

Employed

Marital status

Are you a student?

School Name

Primary Dental Insurance Subscriber

First Name

Last Name

Patients Relationship to Subscriber

Date of birth

Insured Party Gender

Insured Party Phone

Social Security Number

Insured Party Address 1

Insurance Party Address 2

City

State

Zip

Primary Medical Insurance Subscriber

First Name

Last Name

Patients Relationship to Subscriber

Date of birth

Insured Party Gender

Insured Party Phone

Social Security Number

Insured Party Address 1

Insurance Party Address 2

City

State

Zip

Primary Dental Insurance Information

Employer / Business

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address 1

Insurance Company Address 2

City

State

Zip

Phone Number

Group Name

Group Number

Primary Medical Insurance Information

Employer / Business

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address 1

Insurance Company Address 2

City

State

Zip

Phone Number

Group Name

Group Number

Do you have secondary dental or medical insurance?

Health history

To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is a part of your entire body. Health problems that you may have or medication that you may be taking, could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

What is your reason for visiting our practice?

What is your height? (in.)

What is your weight? (lbs.)

Are you in good health?

Have there been any changes in your general health in the past year?

Are you under the care of a physician?

Have you had any illness, operation or been hospitalized in the past five years?

Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?

Do you have a prosthetic joint/implant?

Have you had a heart valve replacement or vascular graft?

Have you ever had general anesthesia?

Have you, or a family member, had any unusual or serious reactions to general anesthesia?

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Is there any condition concerning your health that the doctor should be told about?

Do you wish to speak to the doctor privately about anything?

If you are having surgery today, have you had anything to eat or drink in the last 6 (six) hours?

Who is driving you home?

Mobile Phone

Notify of Pick-up status via

Is there a FAMILY history of

Cancer

Diabetes

Heart Disease

Anesthesia Problems

Autism

Health History Cont.
Have you had or do you currently have...

*Rheumatic fever

*Damaged heart valves/mitral valve prolapse

*Heart murmur

*High blood pressure

*Low blood pressure

*Chest pain/ angina

*Heart attack(s)

*Irregular heart beat

*Cardiac pacemaker

*Heart surgery

*Pneumonia, bronchitis or chronic cough

*Asthma

*Hay fever/sinus problems

*Snoring

*Sleep Apnea / CPAP

*Difficult breathing/other lung trouble

*Tuberculosis

*Emphysema

*Do you smoke or vape?

*Do you use marijuana?

*Do you use chewing tobacco?

*Blood transfusion

*Blood disorder such as anemia

*Bruise easily

*Bleeding tendency/ abnormal bleed

*Hepatitis, jaundice, or liver disease

*Infectious mononucleosis

*Gallbladder trouble

*HIV/AIDS

Have you had or do you currently have...

*Fainting spells

*Convulsions/ epilepsy

*Stroke

*Thyroid trouble

*Diabetes

*Low blood sugar

*Kidney trouble

*High cholesterol

*Are you on dialysis?

*Swollen ankles, arthritis or joint disease

*Osteoporosis/ osteopenia

*Osteonecrosis

*Stomach ulcers/ acid reflux

*Contagious diseases

*Sexually transmitted disease

*Problems with the immune system? Possibly from medication/ surgery, etc.

*Delay in healing

*A tumor or growth

*Cancer, radiation therapy or chemotherapy

*Chronic fatigue/ night sweats

*Are you on a diet?

*A history of alcohol abuse

*A history of drug use?

*Contact lenses

*Eye disease/ glaucoma

*Mental health problems/ anxiety/ depression

*Removable dental appliance

*Pain and clicking of jaws when eating

Pregnancy and Birth Control

Is there a possibility of pregnancy?

Expected delivery date?

Are you nursing?

Are you taking birth control pills?

Date of your last period?

Note: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding other methods of birth control.

Medications Allergies
Medications (Are you now taking...)

Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil)

Have you ever taken diet pills

Any natural product, herbal supplement or homeopathic remedy

Are you taking, or have you ever taken bone density meds, RANKL inhibitors or bisphosphonates such as Denosumab, Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Reclast, or Evista in the past 12 years?

Have you ever taken tranquilizers, sleeping pills, anti-depressants and/or narcotics on a regular basis. If yes, please list:

If you are under the care of a physician for pain management, or recovering from drug addiction please select the medication you are currently taking:

Methadone

Suboxone

Oxycodone

Fentanyl

Other

Other Description

Treating Doctor First Name

Treating Doctor Last Name

Are you allergic or had a reaction to:

Local anesthetic (numbing medication)

Penicillin

Other antibiotics

Sulfa Drugs

Sodium pentothal, Valium, or other tranquilizer

Aspirin

Amoxicillin

Codeine or other narcotics

Latex

Soy

Eggs/Yolk

Sulfites

Do you have any known allergies?

Please list any allergies other than drug allergies?

Are you taking any kind of medication, drug, pills?

Please list any other medications or antibiotics you are allergic to.

Medication / Antibiotic Allergy #1

Medication Name

Conclusion
Emergency Contact Details

First Name

Last Name

Home Phone

Mobile Phone

Relationship to Patient

Accident

Is this related to an accident?

If Yes, What type?

Date of Injury

Insurance Company Handling This Claim

Insurance Claim Number

Name of Attorney / Adjustor

Attorney / Adjustor Phone

ACKNOWLEDGEMENT

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 doctor, or any other member of his / her staff, responsible for any errors or omissions that I have made in the completion of this form. These terms remain in effect throughout my treatment with GBOFS and apply to all services rendered. By signing below, I acknowledge that you have read, understand, and accept these policies.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

FEES, INSURANCE, AND PAYMENT RESPONSIBILITIE

Great Basin Oral & Facial Surgery (GBOFS) is committed to providing high-quality surgical care at the most reasonable cost. We are happy to provide a pre-surgical fee estimate upon request. However, please understand that insurance coverage varies and rarely covers the full cost of surgical procedures. Insurance is designed to help reduce your out-of-pocket expenses but does not eliminate them entirely.

•Understanding Your Coverage - It is my responsibility to review and understand my insurance policy, including deductibles, co-pays, annual maximums, and coverage limitations. GBOFS will submit claims on my behalf to my dental and medical insurance companies as a courtesy, but this does not guarantee coverage or payment for my procedure.

•Patient Financial Responsibility - I am responsible for all costs not covered by my insurance, including deductibles, co-payments, and any fees exceeding my plan’s annual maximum. Payment of my estimated financial responsibility is due at the time of service.

•Claim Processing & Assistance - If my insurance provider delays claim processing, the team at GBOFS may request my assistance to facilitate resolution. I understand that any overpayments received will be refunded to the appropriate party, which may be the patient, guarantor, or insurance company.

•Unpaid Balances & Late Fees - If a balance remains after insurance processing, a statement will be sent to me. Unpaid balances over 30 days will incur a 1.5% finance charge per month.

•Collections & Legal Fees - Accounts sent to collections are subject to additional charges, including up to 30% of the outstanding balance in collection agency fees. If legal action is required, I will also be responsible for any court costs, filing fees, and attorney fees.

•Returned Check Policy - A $25 fee will be charged for checks returned due to insufficient funds.

•Outside Laboratory Fees - Some procedures require the services of outside laboratories (i.e. CBCT scans, biopsy analysis). These fees are separate from my surgical costs and will be billed directly to me by the laboratory.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

Release of Information

•Notice of Privacy Practices - I hereby acknowledge that a copy of GBOFS’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.

•Authorization for Information Disclosure - GBOFS submits insurance claims electronically unless otherwise requested. By receiving treatment, I authorize GBOFS to share necessary health information with my insurance company, claim administrators, and consulting healthcare professionals for the purpose of evaluating and processing claims.

•Insurance Payments - I authorize direct payment of insurance benefits to GBOFS for services provided.

•Appointment Messages - I permit messages to be left on my phone and / or mobile phone concerning my appointment.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

CANCELLATION POLICY

At GBOFS, we value clear communication to ensure a smooth experience for all patients. Our team strives to accommodate your schedule and see you promptly. In return, we ask that you respect your appointment time as we do. GBOFS requires a minimum of 48 hours’ notice for appointment changes or cancellations.

•Late Cancellations & No-Shows - Failure to provide at least 48 hours’ notice will result in a $120 fee.

•Repeated Violations - After two late cancellations or no-shows, future appointments will be limited to same-day scheduling based on availability. After three violations, we will assist you in finding a provider better suited to your scheduling needs.

We understand that unforeseen circumstances arise. If you anticipate a scheduling conflict, please contact us as soon as possible to discuss your options.

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.

MEDICARE BENEFICIARY AGREEMENT

Medicare Private Contract Acknowledgment - I acknowledge that Dr. Daniel Schlieder (NPI 1467725507) and Dr. Jillian Rozanski (NPI 1356682124) have opted out of Medicare from August 18, 2023, to August 17, 2025. I understand my right to seek Medicare-covered services from non-opt-out providers and that this contract does not apply to other practitioners.

As a Medicare beneficiary, I accept full financial responsibility for all services provided by Dr. Schlieder and/or Dr. Rozanski. I understand that Medicare limits do not apply to their charges, and I will not submit claims to Medicare or request the practice to submit a claim on my behalf.do so. I acknowledge that Medicare will not cover these services and that Medigap and other supplemental plans may also refuse payment. This contract cannot be signed during an emergency or urgent care situation, except as permitted by Medicare guidelines (3044.28 of the Medicare Carriers Manual).

*Sign

*Date

By signing, I agree that this signature is the electronic representative of my personal signature for use on all documents including legally binding documents in this office - in just the same way as a pen-and-paper signature.