DSNForms
*First Name
Middle Name
*Last Name
Nickname
*Sex
*Date of birth
Age
Height (IN)
Weight (LB)
Social Security Number
*Cell Phone
Can we text you?
Can we leave a Voicemail?
Email
*Street Address 1
Apt.
*City
*State
*Zip
Occupation
Employer
Who may we thank for referring you to our office?
Pharmacy Name
Pharmacy Telephone Number
Primary Care Physician's Name
Primary Care Office Number
In Case of Emergency Contact
What Brings you in today
*Heart Trouble
*Heart attack(s)
*Cardiac pacemaker
*Fainting spells
*Difficult breathing/other lung trouble
*Low blood pressure
*Stroke
*Acid Reflux Disease
*Hepatitis, jaundice, or liver disease
*Kidney Trouble
*Porta-Catheter
*Heart surgery
*Immune Disorder
*Blood Disorder
*Sickle Cell Anemia
*Artificial Heart Valves
*High blood pressure
*Rhumatic Fever
*Heart Murmur
*Colitis
*Stomach Ulcers
*History of Cancer
*Asthma
*Tuberculosis
*Sleep Apnea
*Seasonal Allergies/Sinus Problems
*Hives/Skin Rash
*Diabetes Insulin Use
*Diabetes Oral Medications
*Low Blood Sugar
*Seizures
*Anemia
*Radiation Treatment on Head/Neck
*Thyroid Problems
*Arthritis
*Knee or Hip Replacement
*Legally Blind
*Glaucoma
*Autism Spectrum Disorder
*Anxiety
*Alzheimer’s / Dementia
Surgeries : Have you been hospitalized or had any surgeries?
If so explain
Sedation: Have you had any negative reaction to sedation in the past
If so please explain
MEDICATIONS: Please list all of the medications that you are currently taking:
Medication #1
Medication #2
Medication #3
Medication #4
Medication #5
Medication #6
Medication #7
Medication #8
Medication #9
Medication #10
Medication #11
Medication #12
Medication #13
Medication #14
Medication #15
Medication #16
Medication #17
Medication #18
Medication #19
Medication #20
Medication #21
Medication #22
Medication #23
Medication #24
Medication #25
Medication #26
Medication #27
Medication #28
Medication #29
Medication #30
Medication #31
Medication #32
Medication #33
Medication #34
Medication #35
Medication #36
Medication #37
Medication #38
Medication #39
Medication #40
Medication #41
Medication #42
Medication #43
Medication #44
Medication #45
Medication #46
Medication #47
Medication #48
Medication #49
Medication #50
ALLERGIES: Please list all allergens and your reaction(s):
*Penicillin
*What is your reaction
*Local Anesthesia
*What is your reaction?
*Aspirin or Nsaids
*Sulfa Drugs
*Latex
What is your reaction
*Others
Smoking: Do you smoke or use smokeless tobacco?
If yes, how much?
Alcohol: Do you drink Alcohol?
If yes, how much and what type?
Recreational Drug: (Marijuana, Cocaine, etc.)
If yes, how much and what type
Is there a possibility of pregnancy?
Do you wish to consult with your physician about the possibility of pregnancy prior to this visit?
Signature or Patient( or Parent if patient is a minor )
Date
OMS of Williamsburg is authorized to release protected health information about the above named patient to entities named below. The purpose is to inform the patient of others in keeping with the patient's instructions.
Who can we release your information to:
What type of information can we release?
Can we leave a voicemail?
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.
*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.
Self (Same as Patient)
Last Name:
First Name:
Date of Birth
SS#
Address ( If different from patient )
Cell Phone ( if different from patient )
*Do you have insurance?
*Subscriber's First Name
*Subscriber's Last Name
*Subscriber's Date of birth
Patient's Relationship to Subscriber
Subscriber's SSN
*Insurance Carrier
*Policy Number
Group Number
Insurance Phone Number
Claims Mailing Address
City
State
Zip
Patients Relationship to Subscriber
Subscriber's SSN#
*Medical Insurance Carrier
Claims Mailing Address:
Do you have Medicare?
***OMS of Williamsburg providers have opted out 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 pre certification 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. 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 $250 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 acknowledgment of receipt, but we must keep a record of your refusal. If you refuse to sign this acknowledgment 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.
Signature of Patient or Legal Representative
First Name
Last Name
Home Phone
Mobile Phone
Relationship to Patient
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
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.
We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form. Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys fees, and court costs.
This signature on file is my authorization for the release of information necessary to process my claim. Reimbursement will go to PT.
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.