Brady J. Semmel DMD, MD

Map Icon1422 Commonwealth Drive, Wilmington, NC 28403

Map Icon910-509-1422
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PATIENT DETAILS










Full Time College Student?
Yes No (CHECK ONE)


Financial Policy
Option A: PAYMENT IS DUE IN FULL AT TIME OF SERVICE

*Cash, personal check, Visa, MasterCard, Discover, American Express or Debit Card accepted

Option B: THIRD PARTY FINANCING

*Patients wishing to finance treatment fees may be eligible for commercial financing. Care Credit is offered and can be applied for at www.carecredit.com. We participate in a 6, and 12 month, no interest option. They also offer longer term financing 24, 36, 48, & 60 month periods with reduced APR and fixed monthly payments.

PLEASE BE AWARE: Any balances past 60 days will be charged interest at the rate of 1.5% monthly (18% APR)

Cancellation Policy: Please call the office within 48 hours of appointment if you wish to cancel your appointment. There will be a 75.00 fee if a 48 hour notice isn’t provided.




RESPONSIBLE PARTY / INSURANCE INFORMATION




Relationship to patient: (CHECK ONE):
Address: Street









Medical History


Were you given any antibiotics or pain medicine?Yes No
Do you have or you had the following diseases or problems?
(CHECK all that apply and then explain)
Heart Disease
Heart Attack
Chest Pain
Coronary Artery Disease
Heart Surgery
Pacemaker
Defect at Birth
Valve Replacement
Irregular Heart Beat
Congestive Heart Failure
History of Bacterial Endocarditis
Other
Breathing Problems
Asthma
Bronchitis
COPD
Emphysema
Sleep Apnea
Shortness of Breath
Tuberculosis
Vascular
High Blood Pressure
Low Blood Pressure
Stroke
TIA
Hardening of the Arteries
Other
Endocrine
Diabetes
(Insulin Dependent or Non-Insulin Dependent)
Hypoglycemia
Thyroid problems
Other
Neurologic
Anxiety
Dementia
Epilepsy
Fainting Spells
Headaches
Seizures
Mentally Handicapped
Other
Liver/Kidney Disease
Hepatitis
Jaundice
Dialysis
Kidney Failure
Kidney Stones
Other
Musculoskeletal
Arthritis
Artificial Joint
Fibromyalgia
MS
Osteoporosis
Other
Gastrointestinal
Ulcers
GERD
Colitis
Crohn’s Disease
Gastric Bypass
Other
Head and Neck
Chronic Sinusitis
Swollen Glands
Difficulty Swallowing
Glaucoma
Radiation Therapy
TMJ Disorder
Other
Hematologic
Anemia
Bleeding Disorder
Blood Transfusions
Hemophilia
Leukemia
Lymphoma
Other
Cancer
Breast
Prostate
Lung
Mouth
Colon
Skin
Uterine
Other Cancer
Chemotherapy
Radiation
Immune System
HIV
AIDS
Immunosuppressive Drug Therapy
(Remicade, Enbrel, Humira)
Other
*Are you to take a “PREMED” antibiotic prior to dental treatment by a medical provider (ex: cardiologist, Orthopedist)? CHECK ONE
Yes
No
Have you taken the following Bisphosphonate Drugs? Fosamax Actonel Boniva Reclast Zometa Aredia
*Do you use tobacco products? CHECK ONE Yes No
*Alcohol use: CHECK ONE None Social or Occasional Daily
*Do you have a history of Drug Abuse? CHECK ONE Yes No
*Are you currently under a Pain Management Contract? CHECK ONE Yes No
*Did you or any family members have complications following previous surgeries?CHECK ONE Yes No
*Did you have Nausea or Vomiting following previous surgeries? CHECK ONE Yes No
*Are you allergic to any of the following? (Please check all that apply)
Amoxicillin
Eggs
Sulfa Medicines
Anesthetics
Latex
Sulfites
Aspirin
Penicillin
Soy
Codeine
Narcotic
Other



HIPPA RECEIPT FORM

Our Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. The Notice contains a Patient Rights section describing your rights under the law. You have the right to review our Notice before signing this Consent. The terms of our Notice may change. If we change our Notice, you may obtain a revised copy by contacting our office.

You have the right to request that we restrict how protected health information about you is used or disclosed for treatment, payment or health care operations. We are not required to agree to this restriction, but if we do, we shall honor that agreement.

By signing this form, you consent to our use and disclosure of protected health information about you for treatment, payment and health care operations. You have the right to revoke this Consent, in writing, signed by you. However, such a revocation shall not affect any disclosures we have already made in reliance on your prior Consent. The Practice provides this form to comply with the Health Insurance Portability and Accountability Act of 1996 (HIPAA).

I authorize Semmel Oral & Facial Surgery to disclose personal medical information to the following people: Drivers/Escorts of sedated patients must be listed below
Yes No I authorize Semmel Oral + Facial Surgery to leave voice messages.

If you (the patient) are having a procedure under sedation, by signing this form you (the patient) will automatically give permission to Semmel Oral & Facial Surgery to disclose personal medical information to your driver/escort on the day of the procedure even if the person is not listed by name on this form.





By submitting this form you agree to the above mentioned consent statement

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Map Icon1422 Commonwealth Drive, Wilmington, NC 28403