DSNForms

North Valdosta Oral & Maxillofacial Surgery - Patient Form

Patient information

*Prefix

*First Name

Middle Initial

*Last Name

*Date of birth

Age

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? If yes, please provide details below.

First Name

Last Name

Relation

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?

Who will be responsible for your account?

Other Description

First Name

Last Name

Date of birth

Social Security Number

Home Phone

Mobile Phone

Email

Street Address 1

Street Address 2

Apt.

City

State

Zip

Employer/Business Name

Home Phone

Spouse or 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 Company

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

Social Security Number

Insured Party First Name

Insured Party Last Name

Relation

Date of birth

Insured Party Gender

Insured Party Phone

Primary Medical Insurance Company

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

Social Security Number

Insured Party First Name

Insured Party Last Name

Relation

Date of birth

Insured Party Gender

Insured Party Phone

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?

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

*Autism

Pregnancy and Birth Control

Is there a possibility of pregnancy?

Expected delivery date?

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
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

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 taking any kind of medication, drug, pills?

Conclusion
Emergency Contact Details

First Name

Last Name

Home Phone

Mobile Phone

Relationship to Patient

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.

OFFICE FINANCIAL POLICY

We appreciate you choosing our practice to provicíe your oral surgery care. The following document is a legal and binding financial policy agreement. Because we value our relationship with you and believe the best relationships are based on understanding, we hope this document provides you with a detailed outline of our Office Financial Policy. By reading and signing this policy, you assume full financial responsibility for any treatment performed by Dr. Fernando Alvarado.

We are happy to file insurance as a courtesy to our patients if we are provided accurate and current insurance information. We must emphasize that as health care providers, our relationship is with you, not your insurance company. Your insurance is a contract between you, your employer, and the insurance company. We are not a party to that contract; therefore your involvement is crucial should there be any conflicts during the processing of the claim.

•We are not a PPO provider with any insurance company.

•If your procedure is medical in nature, we will file your medical insurance as a courtesy. However, we CANNOT FILE Medicaid, Medicare and Tricare for any reason.

•You will be expected to pay any amount that is determined not payable by your insurance plan, such as deductibles and percentages, at the time of service. This amount is based on the treatment plan estimate you will receive prior to surgery.

•The treatment plan estimate is based on the information we obtained from your insurance company. However, this is not a guarantee of benefits or a guarantee that services will be covered. This is STRICTLY AN ESTIMATE. Benefits are determined by your insurance company once the claim is received.

•Once the claim is finalized, you will be responsible for any balance remaining to be paid in full within 30 days. However, if there is a credit balance on the account, a refund will be issued.

•A charge of S35.00 will be assessed on ANY returned check and we will not resubmit the returned check for deposit.

We offer these methods of payment for services rendered:

•Cash, check and all major credit cards. We also offer an outside financing option to assist you if needed.

*Patient Signature (or legal guardian)

*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.

*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

A. Family and Friends - It is our policy not to release confidential medical information regarding your treatment to family members or friends, except for (i) parent/legal guardian, (ii) other persons authorized by the patient, (iii) as we may reasonably infer from circumstances (for example, if you bring a person into the exam or recovery room, we will assume, unless you object, that that person is entitles to receive information regarding your treatment), (iv) in emergency situations, or (v) other as otherwise permitted by the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

If you anticipate that you will need or want your medical information to be provided to family members, friends, or caretakers/babysitters, please indicate that below, so that we may better serve you. If you do not want any of your medical information provided to a family member, please check the line next to "no" response. By signing below, you authorize the following people to receive information regarding your treatment or care. If you later wish to add or remove names, please confirm this in writing or call our office.

-Spouse

Yes
No

-Parent

Yes
No

-Other

Yes
No

B. Alternative Communications: You are also entitled to specify alternative, reasonable means of communication, if you do not wish to be contacted by us in a certain way.

I hereby request the following means of contact only:

PRINTED NAME

*Patient/Parent/Guardian signature

*Date

---------------------------------------------------------------------------------------------

FOR OFFICE USE ONLY

Changes to above authorized by patient over phone:

Change

Date

Staff initials

Change

Date

Staff initials

Change

Date

Staff initials

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 Disclaimer

This agreement is between Fernando Alvarado, DDS, whose principle place of business is 3205 Wildwood Plantation Drive, Valdosta, Georgia, 31605 and

(Print Name)

Please be advised that Femando Alvarado, DDS, has opted out of the Medicare program effective July 1, 2017 and is excluded from participating in Medicare Part B under Sections 1128, 1156, 1892 or any other section of the Social Security Act. Dr, Alvarado agrees to provide oral surgery services to the patient. In exchange for the services the patient agrees to make payment in full to Dr. Alvarado for the services. Patient also agrees, understands and expressly acknowledges thefollowing:

- Patient agrees not to submit a claim (or to request the doctor to submit a claim) to the Medicare program or the Medicare Advantage Dental Program with respect to services, even if covered by Medicare Part B or Medicare Advantage Dental Program

- Patient is not cutrently in an emergency or urgent health care situation.

- Patient acknowledges that neither Medicare's fee limitations nor any other Medicare reimbursement regulations apply to charges for the services,

- Patient acknowledges that Medigap plans will not provide payment or reimbursement for the services because payment is not made under the Medicare Program.

- Patient acknowledges that he/she has a right, as a Medicare beneficiary, to obtain Medicare covered items and services from doctors and practitioners who have not opted out of Medicare, and that the patient is not compelled to enter into private contracts that apply to other Medicare covered services furnished by other doctors or practitioners who have not opted out.

- Patient agrees prior to the services to make payment in full for the services, and acknowledges that Dr. Alvarado will not submit a Medicare claim for the services and that no Medicare reimbursement will be provided.

- Patient understands that Medicare payment will not be made for any items or services furnished by the doctor what would have otherwise been covered by Medicare ifthere were no private contract and proper Medicare claims were submitted.

- Patient acknowledges that a copy of this contract has been made available to him/her,

- Patient agrees to reimburse the doctor for any costs and reasonable attorney fees that result from violation of this agreement by the patient or his/her beneficiaries,

For any questions or concerns regarding your above estimated services and/or fees, please contact our office at 229-247-7585.

Patient Signature

Printed Name

Date

Diplomate, American Board of Oral and Maxillofacial Surgery Diplomate, National Dental Board of Anesthesiology 3205 Wildwood Plantation Dr. « Valdosta, Georgia 31605 - Telephone 229.247.7585 - Fax 229.247.8901