DSNForms

Oral Surgery of Alamo Ranch - AOMS - 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?

General Dentist Name

*First Name

*Last Name

Orthodontist Name

First Name

Last Name

Primary Care Physician 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 of 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 Name

Home Phone

Business Phone

Primary Dental Insurance Subscriber

*First Name

*Last Name

*Patients Relationship to Subscriber

*Date of birth

*Social Security Number

*Insured Party Address 1

*City

*State

*Zip

Primary Medical Insurance Subscriber

*First Name

*Last Name

*Patients Relationship to Subscriber

*Date of birth

*Social Security Number

*Insured Party Address 1

*City

*State

*Zip

Primary Dental Insurance Information

*Employer

*Phone Number

*Ins. Company Name

*Policy I.D. Number

*Ins. Company Address 1

*City

*State

*Zip

*Group Name

*Group Number

Primary Medical Insurance Information

*Employer

*Phone Number

*Ins. Company Name

*Policy I.D. Number

*Ins. Company Address 1

*City

*State

*Zip

*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

*Do you have 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?

Are you nursing?

Are you taking birth control pills?

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 (Bring list to appointment)

*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 allergies

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

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 make every effort to keep down the cost of your 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.

*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.

HIPAA Patient Consent

By signing below, you acknowledge that you have reviewed our Notice of Privacy Practices, which explains how your protected health information (PHI) may be used and disclosed for treatment, payment, and healthcare operations. You understand: You have the right to request restrictions on how your PHI is used. While we are not required to agree, if we do, we will honor the agreement. The practice may update its privacy policy as allowed by law. You will be informed of changes at your next visit. You may revoke this consent in writing at any time. However, any prior use or disclosure made with your consent remains valid. The practice may condition treatment on your signing this consent.

Communication Consent - You authorize us to: Call, text, or email regarding appointments and billing. Leave messages on voicemail or answering machines. Send electronic account statements.

*Sign

Date

Medicare Private Contract Acknowledgment

As a Medicare beneficiary, you are entering a private agreement with the providers at Amarillo Oral and Maxillofacial Surgery, who have formally opted out of the Medicare program. By signing this form, you acknowledge and agree to the following: No Medicare Claims: You will not submit, nor ask our providers to submit, claims to Medicare or its agents for services received here—even if those services would normally be covered. Full Financial Responsibility: You accept full responsibility for all charges for services provided by Amarillo Oral and Maxillofacial Surgery. Medicare and Insurance Limits: You understand that Medicare fee limits do not apply, and that Medicare and some supplemental plans may not reimburse for services rendered under this agreement. Alternative Options: You have the right to seek care from a Medicare-participating provider if you prefer to use your Medicare benefits. No Medicare Payment: You understand Medicare will not pay for any services provided by our office that would have been covered without this agreement. By signing, you confirm that you fully understand and voluntarily accept the terms of this private contract with Amarillo Oral and Maxillofacial Surgery.

*Sign

Date

Notice of Filming and Photography

By entering AOMS / AOMS Pediatric Dentistry, you consent to the possibility of being photographed, filmed, or recorded. These recordings may be used for: Promotional materials Social media and websites News or advertising Live streams or future event highlights Your entry serves as your voluntary consent to the use, publication, or distribution of such media by AOMS. This includes interviews, images, audio, and video recordings. You waive all rights to compensation, royalties, or the ability to review or approve the materials in which you appear. You also release AOMS, its team, and affiliates from any liability related to the capturing or use of this content. By remaining on the premises, you confirm your understanding and acceptance of this notice.

*Sign

Date

Financial Agreement

Payment Policy - Payment is due in full at the time of service. We accept CareCredit, Cherry, and Amarillo National Bank for financing options. By signing below, you accept full responsibility for all charges, regardless of insurance coverage. Any account with an unpaid balance must be resolved before future appointments can be scheduled.

Insurance Information - We will gladly file insurance claims if coverage can be verified. You’ll receive an estimate of your insurance benefits, but please note: Estimates are not guarantees of payment. You are responsible for any portion not covered by your insurance. If payment is not received from your insurer within 5 weeks, you are responsible for the full balance. Any overpayment will be promptly refunded. Insurance is a contract between you and your carrier—you are ultimately responsible for all fees.

Out-of-Network Coverage - It is your responsibility to verify whether your insurance is in-network with the AOMS location you are visiting. If your insurance is out-of-network, we will still file a claim on your behalf, but you must pay any non-covered charges before leaving the office.

No-Show & Late Policy - Appointments are reserved specifically for you. Please notify us at least 24 hours in advance if you need to reschedule. A $25 no-show fee will apply for missed appointments without notice. Patients arriving more than 15 minutes late may be asked to reschedule.

*Sign

Date

Teledentistry Consent Form

You are being offered a teledentistry consultation, which allows a licensed dental provider to deliver care using secure electronic communication while not physically in the same location.

What to Expect - Personal dental and health information may be collected and shared. Dental records, X-rays, images, and video may be securely transmitted. Consultations may be conducted via video, phone, or other technology.

Benefits - Convenient access to care; Improved efficiency in managing dental health

Risks - Potential technical issues or delays; Possibility of incomplete information requiring an in-person visit; While safeguards are in place, there is a small risk of privacy breaches

Your Rights - You may ask questions at any time; You may refuse or withdraw consent at any time; You may request copies of your dental records

Confidentiality - All information shared is confidential and protected under HIPAA. Reasonable measures are in place to maintain secure communication and privacy.

Acknowledgment - By signing, you confirm that you understand and consent to teledentistry services. This consent remains valid until revoked in writing.

*Sign

Date