DSNForms

* - Patient Form

Patient information

*First Name

Middle Name

*Last Name

*Date of birth

Social Security Number

Email

*Gender

Street Address 1

Apt.

City

State

Zip

Primary Phone

Have you ever been a patient of our practice?

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

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
Dentist Name

First Name

Last Name

Orthodontist Name

First Name

Last Name

Medical Doctors Name

Cardiologist First Name

Cardiologist Last Name

Phone Number

Primary Care Physician

First Name

Last Name

Phone Number

Who were you referred by?

First Name

Last Name

Responsible Party

*First Name

*Last Name

*Date of birth

*Social Security Number

*Street Address 1

Street Address 2

Apt.

*City

*State

*Zip

*Phone Number

*Email Address

Patient /Responsible Party Signature

*Signature

*Date

Coverage
No dental insurance/Self Pay
Dental Insurance

Legal First Name

Legal Last Name

Patients Relationship to Subscriber

Date of birth

Dental Insurance Name

Insurance Address

City

State

Zip

Phone Number

Social Security Number

Employer

Member ID

Group Number

Medical Insurance Name

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?

Last Visit Date

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?

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

Have you ever been told you are at risk for malignant hyperthermia?

Do you have any special needs, such as physical impairments, disabilities, or religious and/or ethnic concerns, that we should be aware of to better accommodate your care

If yes, please list below.

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)

GLP1 Agonists - Diabetes or Weight Management (semaglutide, mounjaro, ozempic, wegovy, trulicity)

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?

Are you allergic or had a reaction to:

Local anesthetic (numbing medication)

Describe reaction

Penicillin

Describe reaction

Other antibiotics

Describe reaction

Sulfa Drugs

Describe reaction

Sodium pentothal, Valium, or other tranquilizer

Describe reaction

Aspirin

Describe reaction

Amoxicillin

Describe reaction

Codeine or other narcotics

Describe reaction

Latex

Describe reaction

Soy

Describe reaction

Eggs/Yolk

Describe reaction

Sulfites

Describe reaction

Please list any other allergies?

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

Purpose of Consent

By signing this form, you will consent to our use and disclosure of your protected health information to carry out treatment, payment activities, and healthcare operations. Notice of Privacy Practices: You have the right to read our Notice of Privacy Practices (HIPAA) before you decide whether to sign this Consent. Our Notice provides a description of our treatment, payment activities, and healthcare operations, of the uses and disclosures we may make of your protected health information, and of other important matters about your protected health information. A copy of our Notice accompanies this consent. We encourage you to read it carefully and completely before signing this consent.

We reserve the right to change our privacy practices as described in our Notice of Privacy Practices. If we change our privacy practices, we will issue a revised Notice of Privacy Practices, which will contain the changes. Those changes may apply to any of your protected health information that we maintain.

You may obtain a copy of our Notice of Privacy Practices, including any revisions of our Notice, at any time by contacting:

Management

Telephone: (214) 363-9946

Fax: (214) 389-1953

Address: 8315 Walnut Hill Lane, Suite 225, Dallas, TX 75231

Right to Revoke: You will have the right to revoke this consent at any time by giving us written notice of your revocation submitted to management. Please understand that revocation of this consent will not affect any action we took in reliance on this consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this consent.

I agree that have had full opportunity to read and consider the contents of this consent form and your Notice of Privacy Practices (HIPAA). I understand that, by signing this consent form, I am giving my consent to your use and disclosure of my protected health information to carry out treatment, payment activities and healthcare operations.

Payment Policy

If applicable, as a courtesy, insurance claims will be filed by Dallas Oral Surgery Associates, and I am responsible for paying my estimated portion at the time of service. I understand that if for any reason the account balance is not paid in full within sixty days of the initial visit, it becomes my responsibility without exception.

•For your convenience, we accept cash, check (in state only), VISA, Master, Discover and American Express.

•Responsibilities for payments for minor children, whose parents are divorced, rest with the parent who seeks treatment (This parent is the guarantor). Any court ordered responsibility judgment must be determined between the individuals involved, without the inclusion of Dallas Oral Surgery Associates.

•Unpaid balances may be referred to a third-party collection agency, which may result in additional collection fees that you will be responsible for.

•You must provide your most current billing address, all available telephone numbers, and any important contact information. If this information changes it is your responsibility to contact us with your updated information.

•If your insurance company requires your social security number to file a claim, you will be required to provide it or pay for services received at time of service. We require that payment of deductible, co- pays and co-insurance be paid at the time of service. You are financially responsible for services not covered by your insurance company.

•I understand that Dallas Oral Surgery Associates is out-of-network with all medical insurance companies.

•For insurance questions, please contact our office Monday through Thursday between 8:00am -4:00pm by calling (214) 363-9946.

By signing below, I understand that I am financially responsible for all charges. I also understand that in the event of appointment alterations without adequate (24 hour) notice, additional charges may apply.

INSURANCE

Understanding insurance policies can be challenging for the patient as well as your dental team. Every employer along with the insurance company negotiates the benefits and exclusions of the policy to come up with the best premiums for the employer and employee. Sometimes, in order for premiums to be affordable, the benefits offered might not include everything that is needed to care for the patient. We do verify your dental insurance and get a general benefit summary as a courtesy for our patient. At this time, we are informed from the insurance company that the information is not a guarantee of payment; therefore, we are unable to guarantee any portions paid by the dental insurance company. At the initial exam, you will be provided a treatment plan, which will give you an estimate of your portion due at time of service. Upon request we will also provide you with the necessary codes in the event you have questions for your insurance company pertaining to coverage. Dallas Oral Surgery Associates is not in-network with Medicare and does not submit or file any Medicare claims.

HIPAA POLICY

In General, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual’s office instead of their home.

I wish to be contacted in the following manner (check all that apply):

Home/Cell Phone

Or

Leave a message with callback number only
Mail to address on file
Email (if different)

I allow you to give my clinical information to or answer questions from the following person(s) Please give full name of each person listed:

Spouse

Parent

Child

Escort

Other

By signing this document, I acknowledge that the above information was given to me prior to my surgery, and that I have read and understand the information on patient rights/responsibilities, physician ownership, advance directives, and HIPAA. I agree to the policies of Dallas Oral Surgery Associates. If I have indicated I would like additional information, I acknowledge receipt of that information.

Signature

*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.