Facial and Oral Surgery Specialists - Facial and Oral Surgery Specialists

Demographic Information
Intake
Insurance information
Health History Cont.
Medications Allergies
Conclusion

Patient information

*Prefix

*First Name

Middle Name

*Last Name

*Date of birth

Social Security Number

*Gender at birth

Male Female

Street Address 1

Street Address 2

Apt.

City

State

Zip

Primary Phone

Alternate Phone (Mobile, work, or home)

*Upload your Driver's license

Maximum allowed size : 25MB

Dentist

First Name

Last Name

Orthodontist

First Name

Last Name

Medical Doctor

First Name

Last Name

Approximate Date of last physical ( month and year )

*Preferred Pharmacy

if no preferred pharmacy, please enter na

*Pharmacy Name

Preferred Pharmacy Phone

*Pharmacy Address

Intake

*Reason for Visit/Chief Complaint

When did symptoms/issue start?

What makes symptoms/issue worse/better

How would you describe the symptoms/issue

Rate symptoms/issue from 1-10

Do you have any cosmetic or functional concerns either related or unrelated to your chief complaint(If below do not apply, please move forward to the Referral Information)

Nose

Please Describe

Facial Appearance

Please Describe

Jaw(s) Position/Jawline

Please Describe

Cheekbones

Please Describe

Chin

Please Describe

Neck

Please Describe

Missing Teeth

Please Describe

Smile

Please Describe

Bite

Please Describe

Breathing/Airway

Please Describe

Snoring/Sleep

Please Describe

Facial Pain/TMJ

Please Describe

How did you find us?

Direct referral by healthcare professional?

Type of Healthcare Professional (HCP) ?

First and Last Name of HCP

Practice Name of HCP

Referred by patient of the practice?

First and Last Name of the referring patient

Hospital/Institution Referral?

Hospital/Institution Name?

Google

Chat GPT/Other AI Search

Social Media

Word of Mouth

Landed on Website

Other

If other Please describe

Insurance information

General Insurance information

Employed

Marital status

Are you a student?

Full-Time Part-Time Not a Student

School Name

*Do you have Dental Insurance

Yes No

Dental Insurance Information

Upload the front of your dental insurance card

Maximum allowed size : 25MB

Upload the back your dental insurance card

Maximum allowed size : 25MB

Employer / Business

Phone Number

Plan Name

Ins. Company Name

Policy I.D. Number

Ins. Company Address 1

Ins. Company Address 2

City

State

Zip code

Phone Number

Group Name

Group Number

Dental Insurance Subscriber

First Name

Last Name

Patients Relationship to Subscriber

Date of Birth

Insured Party Gender

Insured Party Phone

SSN

Insured Party Address 1

Insured Party Address 2

City

state

Zip code

*Do you have Secondary Dental Insurance?

Yes No

Secondary Dental Insurance Information

Upload the front of your dental insurance card

Maximum allowed size : 25MB

Upload the back of your dental insurance card

Maximum allowed size : 25MB

Employer / Business

Phone Number

Plan Name

Ins Company Name

Policy ID Number

Insurance Company Address 1

Insurance Company Address 2

City

State

Zip

Group Name

Group Number

Secondary Dental Subscriber Information

First Name

Last Name

Patients Relationship to Subscriber

Date of Birth

Insured Party Gender

Male Female

Insured Party Phone

Social Security

Insured Party Address 1

Insured Party Address 2

City

State

Zip

*Do you have Medical Insurance

Yes No

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

Primary Medical Insurance Subscriber

Upload the front of your Medical Insurance Card

Maximum allowed size : 25MB

Upload the back of your medical insurance card

Maximum allowed size : 25MB

First Name

Last Name

Patients Relationship to Subscriber

Date of birth

Insured Party Gender

Male Female

Insured Party Phone

Social Security Number

Insured Party Address 1

Insurance Party Address 2

City

State

Zip

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 height? (Ft.)

inches

What is your weight? (lbs.)

Are you in good health?

Yes No

Have there been any changes to your health in the last year?

Yes No

Please describe them

Have you had any illness, operation or been hospitalized in the past five years?

Yes No

Please describe

Do you have unhealed/recurrent injuries or inflamed areas, growths or sore spots in or around your mouth?

Yes No

Please describe

Do you have a prosthetic joint/implant?

Yes No

Please describe

Have you had a heart valve replacement or vascular graft?

Yes No

Please describe

Have you ever had general anesthesia?

Yes No

Please describe

Have you, or a family member, had any unusual or serious reactions to general anesthesia?

Yes No

Please describe

Has a physician or dentist recommended that you take antibiotics prior to dental treatment?

Yes No

Please describe

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

Yes No

Please describe

If you are having a procedure with sedation or general anesthesia today, have you had anything to eat or drink in the last 8 hours?

Yes No

Who is driving you home?

Mobile Phone

Notify of Pick-up status via

Text Phone Call

Is there a FAMILY history of

Cancer

Yes No

Diabetes

Yes No

Heart Disease

Yes No

Anesthesia Problems

Yes No

Health History Cont.

Have you had or do you currently have...

*Rheumatic fever

Yes No

*Damaged heart valves/mitral valve prolapse

Yes No

*Heart murmur

Yes No

*High blood pressure

Yes No

*Low blood pressure

Yes No

*Chest pain/ angina

Yes No

*Heart attack(s)

Yes No

*Irregular heart beat

Yes No

*Cardiac pacemaker

Yes No

*Heart surgery

Yes No

*Pneumonia, bronchitis or chronic cough

Yes No

*Asthma

Yes No

*Hay fever/sinus problems

Yes No

*Snoring

Yes No

*Sleep Apnea / CPAP

Yes No

*Difficult breathing/other lung trouble

Yes No

*Tuberculosis

Yes No

*Emphysema

Yes No

*Do you smoke or vape?

Yes No

If so, how much a day?

*Do you use marijuana?

Yes No

*Do you use chewing tobacco?

Yes No

*Blood transfusion

Yes No

*Blood disorder such as anemia

Yes No

*Bruise easily

Yes No

*Bleeding tendency/ abnormal bleed

Yes No

*Hepatitis, jaundice, or liver disease

Yes No

*Infectious mononucleosis

Yes No

*Gallbladder trouble

Yes No

*HIV/AIDS

Yes No

Have you had or do you currently have...

*Fainting spells

Yes No

*Convulsions/ epilepsy

Yes No

*Stroke

Yes No

*Thyroid trouble

Yes No

*Diabetes

Yes No

*Low blood sugar

Yes No

*Kidney trouble

Yes No

*High cholesterol

Yes No

*Are you on dialysis?

Yes No

*Swollen ankles, arthritis or joint disease

Yes No

*Osteoporosis/ osteopenia

Yes No

*Osteonecrosis

Yes No

*Stomach ulcers/ acid reflux

Yes No

*Contagious diseases

Yes No

*Sexually transmitted disease

Yes No

*Problems with the immune system? Possibly from medication/ surgery, etc.

Yes No

*Delay in healing

Yes No

*A tumor or growth

Yes No

*Cancer, radiation therapy or chemotherapy

Yes No

*Chronic fatigue/ night sweats

Yes No

*Are you on a diet?

Yes No

*A history of alcohol abuse

Yes No

*A history of drug use?

Yes No

*Contact lenses

Yes No

*Eye disease/ glaucoma

Yes No

*Mental health problems/ anxiety/ depression

Yes No

*Removable dental appliance

Yes No

*Pain and clicking of jaws when eating

Yes No

Pregnancy and Birth Control

Is there a possibility of pregnancy?

Yes No

Expected delivery date?

Are you nursing?

Yes No

Are you taking birth control pills?

Yes No

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)

Yes No

Any diet pills or injections, including GLP-1 or like medications?

Yes No

Any natural product, herbal supplement or homeopathic remedy

Yes No

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?

Yes No

Tranquilizers, sleeping pills, anti-depressants and/or narcotics on a regular basis. If yes, please list:

Yes No

please list

Are you allergic or have had a reaction to:

Local anesthetic (numbing medication)

Yes No

Please describe the reaction

Penicillin

Yes No

Please describe the reaction

Other antibiotics

Yes No

Please describe the reaction

Sulfa Drugs

Yes No

Please describe the reaction

Sodium pentothal, Valium, or other tranquilizer

Yes No

Please describe the reaction

Aspirin

Yes No

Please describe the reaction

Amoxicillin

Yes No

Please describe the reaction

Codeine or other narcotics

Yes No

Please describe the reaction

Latex

Yes No

Please describe the reaction

Soy

Yes No

Please describe the reaction

Eggs/Yolk

Yes No

Please describe the reaction

Sulfites

Yes No

Please describe the reaction

Do you have any other known allergies not listed above?

Yes No

Please describe

Please list any allergies other than drug allergies?

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

Yes No

Please list any medications you are currently taking

Medication #1

Medication Name

Dosage

Frequency

Medication #2

Medication Name

Dosage

Frequency

Medication #3

Medication Name

Dosage

Frequency

Medication #4

Medication Name

Dosage

Frequency

Medication #5

Medication Name

Dosage

Frequency

Medication #6

Medication Name

Dosage

Frequency

Medication #7

Medication Name

Dosage

Frequency

Medication #8

Medication Name

Dosage

Frequency

Medication #9

Medication Name

Dosage

Frequency

Medication #10

Medication Name

Dosage

Frequency

Conclusion

Emergency Contact Details

First Name

Last Name

Home Phone

Mobile Phone

Relationship to Patient

Accident

Is this related to an accident?

Yes No

If Yes, What type?

Automobile Work Related Other

Date of Injury

Insurance Company Handling This Claim

Insurance Claim Number

Name of Attorney / Adjustor

Attorney / Adjustor Phone

ACKNOWLEDGEMENT

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. These terms remain in effect throughout my treatment with Facial and Oral Specialists and apply to all services rendered. By signing below, I acknowledge that I have read, understand, and accept these policies.

*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, INSURANCE, AND PAYMENT RESPONSIBILITIES

Facial and Oral Specialists (FOSS) is committed to providing high-quality surgical care at the most reasonable cost. We are happy to provide a pre-surgical fee estimate upon request. However, please understand that insurance coverage varies and rarely covers the full cost of surgical procedures. Insurance is designed to help reduce your out-of-pocket expenses but does not eliminate them entirely.

· Understanding Your Coverage. It is my responsibility to review and understand my insurance policy, including deductibles, co-pays, annual maximums, and coverage limitations. FOSS will submit claims on my behalf to my dental and medical insurance companies as a courtesy, but this does not guarantee coverage or payment for my procedure.

· Patient Financial Responsibility. I am responsible for all costs not covered by my insurance, including deductibles, co-payments, and any fees exceeding my plan’s annual maximum. Payment of my estimated financial responsibility is due at the time of service.

· Claim Processing & Assistance. If my insurance provider delays claim processing, the team at FOSS may request my assistance to facilitate resolution. I understand that any overpayments received will be refunded to the appropriate party, which may be the patient, guarantor, or insurance company.

· Unpaid Balances & Late Fees. If a balance remains after insurance processing, a statement will be sent to me. Unpaid balances over 30 days will incur a 1.5% finance charge per month.

· Collections & Legal Fees. Accounts sent to collections are subject to additional charges, including up to 30% of the outstanding balance in collection agency fees. If legal action is required, I will also be responsible for any court costs, filing fees, and attorney fees.

· Returned Check Policy. A $25 fee will be charged for checks returned due to insufficient funds

· Outside Laboratory Fees. Some procedures require the services of outside laboratories (i.e. CBCT scans, biopsy analysis). These fees are separate from my surgical costs and will be billed directly to me by the laboratory.

*Sign

*Date

NOTICE OF PRIVACY PRACTICES AND RELEASE OF INFORMATION

· Notice of Privacy Practices. I hereby acknowledge that a copy of FOSS’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 Information Disclosure. FOSS submits insurance claims electronically unless otherwise requested. By receiving treatment, I authorize FOSS to share necessary health information with my insurance company, claim administrators, and consulting healthcare professionals for the purpose of evaluating and processing claims.

· Insurance Payments. I authorize direct payment of insurance benefits to FOSS for services provided.

· Appointment Messages. I permit messages to be left on my phone and / or mobile phone concerning my appointment.

*Sign

*Date

CANCELLATION POLICY

At Facial and Oral Specialists (FOSS), we value clear communication to ensure a smooth experience for all patients. Our team strives to accommodate your schedule and see you promptly. In return, we ask that you respect your appointment time as we do.

FOSS requires a minimum of 48 hours’ notice for appointment changes or cancellations.

· Late Cancellations & No-Shows: Failure to provide at least 48 hours’ notice will result in a $50 fee for a late cancellation and $100 fee for a missed appointment.

· Repeated Violations: After two late cancellations or no-shows, we will no longer be able to schedule future appointments.

We understand that unforeseen circumstances arise. If you anticipate a scheduling conflict, please contact us as soon as possible to discuss your options.

*Sign

*Date

MEDICARE BENEFICIARY AGREEMENT - Medicare Private Contract Acknowledgment

I acknowledge that Dr. Tarek Korban (NPI 1: 1598095267) is opted out of Medicare from January 21, 2026, to January 21, 2028, and that Dr. Matthew Clark (NPI 1: 1396905188) is opted out of Medicare from January 21, 2026, to January 21, 2028. I understand my right to seek Medicare-covered services from non-opt-out providers and that this contract does not apply to other practitioners.

As a Medicare beneficiary, I accept full financial responsibility for all services provided by Drs. Tarek Korban and Matthew Clark. I understand that Medicare limits do not apply to their charges, and I will not submit claims to Medicare or request the practice to submit a claim on my behalf. I acknowledge that Medicare will not cover these services and that Medigap and other supplemental plans may also refuse payment.

This contract cannot be signed during an emergency or urgent care situation, except as permitted by Medicare guidelines (3044.28 of the Medicare Carriers Manual).

*Sign

*Date

PATIENT PHOTOGRAPHY RELEASE FORM

I grant the doctors of Oral and Facial Specialists and their staff permission to take and use photographs and digital images of me for the purpose of:

*Teaching (i.e. Educational materials)

Yes No

*Marketing (i.e. Website, brochures, etc.)

Yes No

I do not grant permission of use of my photographs and/or digital images to be published.

I understand that once my photograph(s) or digital image(s) have been released, the surgeon and his/her practice may no longer have control over them, and federal or state privacy laws may no longer protect the information that was released.

I may cancel this authorization to the extent allowed by law. If I do, I understand that the doctor and/or practice may have already used my photograph(s) or digital image(s) prior to me canceling this authorization, which would not prohibit any release done prior to the date of cancelation.

To cancel this agreement, I must write a letter to the doctor or practice advising of my wish to cancel my authorization to release photograph(s) or digital image(s) taken of me by this practice. I (or my authorized representative) must sign and date the letter.

If this authorization has not been canceled, it will expire five (5) years after the date signed.

*Sign

*Date

CONSENT FOR USE OF AI

To enhance your care experience and improve clinical documentation, our office may use ambient listening technology-a HIPAA compliant, secure, AI-enabled system that captures conversations between you and your provider to assist with generating medical documentation.

*I consent to the use of ambient listening technology during my medical visits for the purpose of clinical documentation.

Yes No

*Sign

*Date

Facial and Oral Surgery Specialists - Patient Form

Patient information

Dentist

Orthodontist

Medical Doctor

Intake

How did you find us?

Insurance information

Dental Insurance Information

Dental Insurance Subscriber

Secondary Dental Insurance Information

Secondary Dental Subscriber Information

Primary Medical Insurance Information

Primary Medical Insurance Subscriber

Health history

Is there a FAMILY history of

Health History Cont.

Have you had or do you currently have...

Have you had or do you currently have...

Pregnancy and Birth Control

Medications Allergies

Medications (Are you now taking...)

Are you allergic or have had a reaction to:

Please list any medications you are currently taking

Conclusion

Emergency Contact Details

Accident

ACKNOWLEDGEMENT

FEES, INSURANCE, AND PAYMENT RESPONSIBILITIES

NOTICE OF PRIVACY PRACTICES AND RELEASE OF INFORMATION

CANCELLATION POLICY

MEDICARE BENEFICIARY AGREEMENT - Medicare Private Contract Acknowledgment

PATIENT PHOTOGRAPHY RELEASE FORM

CONSENT FOR USE OF AI