DSNForms

Columbus Oral Surgery - Columbus 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

*Primary Phone Type

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

*Preferred Pharmacy Address

Upload your Driver's license

Maximum allowed size : 25MB

Upload your insurance card

Maximum allowed size : 25MB

Upload 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

*Do you have primary 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?

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 taking any kind of medication, drug, pills?

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

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.

Financial Policy

Thank you for choosing Oral & Facial Surgeons of Ohio (Drs. Rekos, Border and Associates) for your oral & maxillofacial surgery needs. We are committed to providing the services you expect in a safe, friendly, and professional manner.

Patients who do not have medical or dental insurance

Payment is expected in full prior to the services being rendered.

Patients who have verified medical and/or dental insurance benefits

Co-pay is expected prior to the services being rendered and you will be responsible for anything not covered. As a courtesy to you, we will file a claim with your insurance carrier. Any credit due to you will be refunded or applied to future services.

*This is an estimate. If you would like a predetermination of benefits from your insurance carrier, this can be arranged at your request and typically requires 4-6 weeks to be processed*

Payment Options

  • Cash, check, MasterCard, Visa, Discover, American Express or debit cards are acceptable.
  • H.S.A. and Flexible Spending benefit cards or checks are acceptable.
  • Care Credit is available for those patients who prefer to extend payments beyond the conclusion of treatment. We are pleased to offer Care Credit; the American Dental Association approved commercial line of credit specifically designed for the payment of dental care. To learn more about this option, feel free to speak to the financial office.

**PLEASE NOTE** Financing options such as Care Credit are not available in conjunction with the courtesy discount and/or in-network dental plans

Account Refunds

Accounts reflecting a credit balance after insurance payment is received, change of treatment plan, etc. will be refunded via check. Refunds will be issued within 45 days of your account being finalized.

Please note the following:

  • Any quoted fees are an estimate only and are valid for a period of 6 months.
  • The financial obligation for services received is your responsibility and not the responsibility of Oral & Facial Surgeons of Ohio or your insurance carrier.
  • We will file with your primary medical and primary dental insurance carrier. We will file to a secondary dental insurance carrier should a balance remain on the account after primary payment is received.
  • Account balance is due within 30 days of the first statement received.
  • In the event your account becomes delinquent, you may be responsible for any and/or all collection fees.

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.

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.

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.

**PLEASE TYPE OR DRAW YOUR SINGNATURE FOR AUTHORIZATION, OTHERWISE YOU WILL BE ASKED TO FILL OUT THIS FORM WHEN YOU ARRIVE FOR YOUR APPOINTMENT.**