DSNForms

Granite State Oral Surgery - 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?

Preferred Pharmacy

Preferred Pharmacy Phone Number

Dentist Name

First Name

Last Name

Orthodontist Name

First Name

Last Name

Medical Doctor Name

First Name

Last Name

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

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

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...)

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

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?

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

Medication / Antibiotic Allergy #1

Medication Name

AI Disclosure and AI-Assisted Documentation Consent Form

Patient Name

Date of Birth

AI Disclosure

We are committed to providing high-quality clinical care while incorporating advanced technology to enhance efficiency and accuracy. As part of this commitment, we use artificial intelligence (AI) tools to support administrative and management tasks. These tools do not provide treatment or make independent clinical decisions. The specific purposes for which we may use AI include managing appointment scheduling, pre-authorizations and verifications, recording and summarizing clinical discussions, processing billing and insurance claims, handling communications such as appointment reminders and call trees, and analyzing data to track clinical progress, which is reviewed by your provider.

Understanding AI-Assisted Documentation

Our providers may utilize an AI scribe or notetaker to record and assist with documenting your visit. Using AI this way streamlines the preparation of clinical notes and helps ensure comprehensive and precise medical records, while allowing your provider to focus on you during your visit.

• The AI used during your appointment records, transcribes and summarizes discussions between you and your provider.

• The AI does not make clinical decisions or replace the expertise of your provider.

• The AI prepares notes that are incorporated into your medical record. Your provider will review, edit, and finalize all AI-generated documentation to ensure accuracy and completeness. This review addresses the risk of AI transcription errors and potential limits in recognizing certain accents or speech patterns.

• The AI does not share your information with any third parties, and all information is kept confidential and secure, in compliance with HIPAA Privacy and Security regulations.

Your Consent and Rights

Participation in AI-assisted documentation is voluntary. You have the right to decline its use without any impact on your care.

• You may request to review the notes documented with AI assistance.

• You may withdraw your consent at any time by informing your provider or clinic staff.

• You have the right to have any questions or concerns regarding AI-assisted documentation answered by your provider.

By signing below, you acknowledge that you have read and understand the AI disclosure and information provided about AI-assisted documentation and have had the opportunity to ask questions about these.

I hereby consent, to have AI record, transcribe and summarize clinical conversations with the providers
I hereby do not consent, to have AI record, transcribe and summarize clinical conversations with the providers.

*Patient/Patient Representative Signature

*Date

I understand that text messaging on my personal cellphone is not a secure communication method, and that such text messages cannot be encrypted end-to-end and may be intercepted and accessed by third parties, stored indefinitely by mobile carriers, or accessed by other individuals who have access to my phone.

I herby

to communications via text messages on my cell phone.

Patient/Patient Representative Signature

Date

Conclusion

I understand that text messaging on my personal cellphone is not a secure communication method, and that such text messages cannot be encrypted end-to-end and may be intercepted and accessed by third parties, stored indefinitely by mobile carriers, or accessed by other individuals who have access to my phone.

I herby

to communications via text messages on my cell phone.

Patient/Patient Representative Signature

Date

Verification

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.

*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 & PAYMENTS

We at Granite State Oral Surgery believe that every patient is entitled to the highest quality of oral and maxillo-facial surgical care available. Your health and well-being are our first priority. We understand the consideration you give to the cost of your care. We encourage you to be familiar with your own insurance coverage, and we want you to be informed about your proposed surgery and the fees associated with your treatment to prevent any misunderstanding. We are available to discuss any concerns that you might have. We participate with the following insurance companies: Northeast Delta Dental (including USA/Premier programs) and Anthem Blue Cross Blue Shield medical insurance. As a courtesy, we will submit claims to other insurance companies which we do not participate with provided we have all necessary information regarding your coverage. Patients are still ultimately responsible for any fees insurance companies do not cover. We cannot accept responsibility for collecting insurance claims or for negotiating settlements on disputed claims. Payment is due at time of service. The amount due is determined by what insurance benefits you have available. The methods for calculating co-payment are: No insurance: Payment is due in full at time of service. Such payments may be made with cash, check, Visa/Mastercard, American Express. We also offer affordable financing options through Care Credit and Lending Club. Participating Insurance Company: A deposit based on your individual benefits and the services being rendered will be calculated at time of service. Based on our experience, this is an approximate estimate of what is likely to be paid by your insurance company. Any insurance claims outstanding for more than 60 days will be billed to the guarantor on the account. Balances after insurance pays: When a balance remains on an account, payment is due within thirty days. A finance charge of 1% will be added to the account each month that there is an outstanding balance. This represents an annual percentage rate of twelve percent (12%). Overpayment by Insurance: If your insurance company’s correct payment results in an overpayment on your account, a refund will be issued to you. Financial Understanding I understand that Granite State Oral Surgery, PLLC, has not offered me any assurances or determination that my insurance will pay for my care. I understand that I may ask my insurance company for a pre-treatment estimate of benefits, but that I remain responsible for all fees not paid by my insurance. Understanding this policy statement, I accept financial responsibility to Granite State Oral Surgery, PLLC, for services rendered. I authorize release of any information relating to this claim. I authorize payment directly to Granite State Oral Surgery, PLLC, of insurance benefits otherwise payable to me. I also understand that if it becomes necessary to place this account with a collection agency, I will be responsible to pay an additional 35% of the outstanding balance to cover the collection costs.

*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

This signature on file is my authorization for the release of information necessary to process my claim. Reimbursement will go to PT.

*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.

Authorization for Service

I authorize my surgeon and her designated 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 a 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 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.

Notice of Privacy Practices

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.

*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.