New Patient Forms - Chase Pruitt Oral Surgery

Patient Information:

Date*

Patient Name*

First Name Middle Initial Last Name

DOB*

SSN

Sex

Email*

Address*

Street Address City State ZIP Code

Phone*

Referring Doctor*

Preferred Pharmacy

Phone

Emergency Contact

Phone

Primary Dental Insurance:

Self Pay

Policy Holder/Subscriber/Member Name*

Relation*

DOB*

Policy Holder SSN*

Sex

Phone*

Employer*

Insurance Company*

Member ID*

Subscriber Address*

Secondary Dental Insurance:

No Secondary Insurance

Policy Holder/Subscriber/Member Name*

Relation*

DOB*

Policy Holder SSN*

Sex

Phone*

Employer*

Insurance Company*

Member ID*

Subscriber Address*

Upload Insurance Cards:

Upload Front of the Insurance Card*

Max. file size: 10 MB.

Upload Back of the Insurance Card*

Max. file size: 10 MB.

Upload Photo ID*

Max. file size: 10 MB.

Medical History:

Have you had, or do you currently have:

Difficulty breathing/ lung trouble?*

Yes

Bleeding tendency/ abnormal bleeding?*

Yes

High blood pressure?*

Yes

HIV/AIDS?*

Yes

Convulsions/ epilepsy?*

Yes

Heart attacks?*

Yes

Stroke?*

Yes

Diabetes?*

Yes

Asthma?*

Yes

Sleep apnea/ CPAP?*

Yes

Osteoporosis/ Osteopenia?*

Yes

Mental health / anxiety/ depression?*

Yes

Cancer, radiation therapy, or chemotherapy?*

Yes

Social History:

Smoke/ Vape?*

Yes

Marijuanna or recreational drug use?*

Yes

Chewing tobacco?*

Yes

Alcohol use?*

Yes

Medications and Allergies:

Medications:*

List all current medications.

Allergies:*

List all allergies.

Any additional health related concerns the doctor should be made aware of?

Past Procedures:

Have you had any procedures or surgeries? Describe.*

Have you had general anesthesia? Any complications? Describe.*

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.

Signature:*

Date

Release of Information:

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

Signature:*

Date

Fees and Payments:

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.

Signature:*

Date

Authorization for Service:

I authorize my surgeon and his / 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.

Signature:*

Date

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.

Signature:*

Date

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