DSNForms
*First Name
Middle Name
*Last Name
Nickname
*Sex
*Date of birth
*Age
*Height( In )
*Weight( lbs )
Social Security Number
Cell Phone
Can we text you
Can we leave a voice mail
Email
Street Address 1
Apt.
City
State
Zip
Who may we thank for reffering you to our office?
*Preferred Pharmacy Name
*Preferred Pharmacy Phone
Upload your Driver's license
Upload your insurance card
Upload the back your insurance card
Name
Phone number
In case of emergency contact
What brings you in today
*Heart Trouble
*Heart Attack
*Pace-Maker
*Fainting Spells
*Difficulty Breathing
*Heart Mumur
*Artificial Heart Valves
*Rheumatic Fever
*High Blood Pressure
*Low Blood Pressure
*Stroke
*Acid Reflux
*Stomach Ulcers
*Colitis
*Hepatitis/Liver Disease
*Kidney Trouble
*Porta-Catheter
*Immune Disorder
*Blood Disorder
*Sickle Cell Anemia
*History of Cancer
*Asthma
*COPD
*Tuburculosis
*Sleep Apnea
*Seasonal Allergies/ Sinus Problems
*Hives/Rash
*Diabetes Insulin Use
*Diabetes Oral Medication
*Low Blood Sugar
*Seizures
*Anemia
*Radiation Treatment of Head/Neck
*Thyroid Problems
*Athritis
*Knee or Hip Replacement
*Legally Blind
*Glaucoma
*Autism Spectrum Disorder
*Anxiety
*Alzheimer's/ Dementia
Other Conditions
I certify that, to the best of my knowledge, none of the above health conditions apply to me.
Do you need to premedicate before dental appointments?
If yes explain
Sedation: Have you had any negative reaction to sedation in the past ( e.g., nausea, vomiting, etc.) or a Family History of Anesthesia Complications
Have you been hospitalized or had any surgeries?
*Blood thinners (Coumadin, Plavix, Aspirin, Vitamin E, Ginko biloba, Aggrenox, Pradaxa, Fish oil)
*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?
*Use of GLP-1 medications (ie Ozempic, Wegovy, etc)
*Use of Biologic medications (ie Humira, Stelara , etc)
*Immune Suppressive Medications
Please list all medications and dosages
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Medication #9
Medication #10
Allergies: Please list all allergens and your reactions
*Are you allergic to Penicillin?
Please list reaction
*Are you allergic to Local Anesthesia
*Aspirin or NSAIDS
*Sulfa Drugs
*Latex
*Other
Do you Smoke or use Smokeless tobacco?
If so how much
Do you drink Alcohol
If yes how much and what type?
Do you do recreational drugs ( Marijuana, Cocaine, etc.)
If yes what type and how much?
- Any elective surgery and anesthesia during pregnancy is potentially harmful to the developing fetus. You have the option of consulting with your physician to rule out a pregnancy before your surgical procedure.
Is there a possibility of pregnancy?
Do you wish to consult with your physician about the possibility of pregnancy prior to this visit?
Are you taking birth control pills?
Signature of Patient ( or Parent if patient is a minor )
Date
Pinnacle Oral & Maxillofacial Surgery is authorized to release protected health information about the above-named patient to the entities named below. The purpose is to inform the patient or others in keeping with the patient’s instructions.
Who can we release your information to?
What type of information can we release?
I understand that I have the right to revoke this authorization at any time and to inspect or copy the protected health information to be disclosed as described in this document. I acknowledge that revocation will not affect disclosures already made but will apply to future disclosures. I also understand that information disclosed under this authorization may be subject to re-disclosure by the recipient and may no longer be protected by federal or state law. This authorization remains in effect until revoked by the patient.
*Signature of Patient or Legal Representative
Self ( same as patient )
Last Name
First Name
Date of Birth
Relationship to Patient
SSN
Mobile Phone ( If different from patient )
Address ( If different from patient )
Subscriber's name
Subscriber's DOB
Subscriberr's SSN
Insurance Carrier
Policy #
Group #
Employer
Insurance Phone #
Claims Mailing Address
Subscriber's SSN
Employer:
Claims mailing address:
Do you have Medicare ?
*** NU Image providers have opted our of Medicare Part B ***
Insurance & Payment Policy
As a courtesy, we file dental insurance claims on your behalf. To do so, your insurance information must be provided and verified at the time of service. If not, full payment is required on the day of your visit. You are responsible for the estimated patient portion based on your insurance benefits. Please note that insurance estimates are not guarantees of payment; final coverage amounts are determined by your insurer once the claim is processed. Some insurance plans use reduced fee schedules for oral and maxillofacial surgery, which may result in lower coverage than expected, based on the plan you or your employer select. It is your responsibility to verify any precertification or second opinion requirements with your insurer before treatment. Remember, your dental insurance contract is between you and your insurance provider. You are ultimately responsible for any unpaid balance, and co-insurance cannot be waived.
For Patients Without Insurance
If you do not have insurance, payment is due in full at the time of treatment. We accept MasterCard, Visa, Discover, and American Express. Financing options are available through CareCredit, Lending Club, and Proceed Financing pending credit approval. Please ask our patient care coordinators for more information.
Please note: There will be a $30.00 fee for returned checks and a fee of $200 for broken appointments. Appointment cancellations require 48 hours’ notice.
*Please sign that you have read and agree to the above conditions:
Acknowledgement of Receipt of Notice of Privacy Practices
Notice to Patient: We are required to provide you with a copy of our Notice of Privacy Practices which states how we may use and/or disclose your health information. Please sign this form to acknowledge receipt of the Notice. You may refuse to sign this acknowledgement of receipt, but we must keep a record of your refusal. If you refuse to sign this acknowledgement of receipt, we are required to treat you and we may still use and/or disclose your health information as HIPAA permits. I acknowledge that I have received a copy of this office’s Notice of Privacy practices.