Fees and Payment Information
Please read and enter your initials after each paragraph below.
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. If you have any dental and/or medical insurance, we will be glad to fill out the proper forms, but please complete the identify information below.
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. A 1-1/2% finance charge (18% annually) will be added to any balance over 30 days. I further agree that I will be responsible for all collection costs, attorney's fees and court costs.
By entering my full name below, I am authorizing the release of information necessary to process my claim. I hereby authorize payments to this doctor named of the benefits otherwise payable to me.
Your 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.
Reason for today's office visit (select those for which your answer is "yes"):
Have you had or do you currently have any of the following? (Select all that apply.)
Are you now taking any of the following medication? (Select all that you are taking.)
Are you allergic to or have you had a reaction to any of the following? (Select all that apply.)
Do you have a family history of any of the following? (Select all that apply.)
NOTE TO WOMEN: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician / gynecologist for assistance regarding additional methods of birth control.
Your Digital Signature
By entering my full name below, I certify that I have read and 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 surgeon, or any other member of his / her staff responsible for any errors or omissions that I have made in the completion of this form.
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