New Patient Form PATIENT DETAILS Name: First MI Last Nickname GenderGenderFemaleMale Race Date of birth SSN/ID#: Patient's Address Apt:s City State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Home Phone Cell Phone Work phone E-Mail Primary Medical Doctor Emergency Contact Emergency contact phone How did you hear about our office General Dentist Primary Medical Doctor Full Time College Student? Yes No (CHECK ONE) If yes, name of school Pharmacy Pharmacy phone 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. Select the Financial Option you would like to be used for your account: Select An Option Option A Option B 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. Typed Name/Signature Relationship to Patient Date RESPONSIBLE PARTY / INSURANCE INFORMATION Name: First MI Last Last Relationship to patient: (CHECK ONE): Self Spouse Parent Guardian Other (specify) Address: Street City State State Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware District Of Columbia Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington West Virginia Wisconsin Wyoming Zip Phone Number Date of birth Employer Insurance Company Name Secondary Insurance Medical History Name Date Date GenderGenderFemaleMale Height Weight Why are you here today? 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 Females: Pregnant, Breast Feeding, other *Are you to take a “PREMED” antibiotic prior to dental treatment by a medical provider (ex: cardiologist, Orthopedist)? CHECK ONE Yes No If yes, which antibiotic? For what medical condition? Have you taken the following Bisphosphonate Drugs? Fosamax Actonel Boniva Reclast Zometa Aredia *Do you use tobacco products? CHECK ONE Yes No If yes, what products and how often? *Alcohol use: CHECK ONE None Social or Occasional Daily *Do you have a history of Drug Abuse? CHECK ONE Yes No Please explain: *Are you currently under a Pain Management Contract? CHECK ONE Yes No If yes, please list your doctor: *Please list ALL previous SURGERIES you have had with SEDATION (ex: colonoscopy) and dates: *Did you or any family members have complications following previous surgeries?CHECK ONE Yes No Please explain: *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 If other explain: *Please list all current MEDICATIONS, HERBAL and/or VITAMINS that you are taking: Typed Name/Signature Relationship to Patient Date 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 Name Relationship Name Relationship Name Relationship 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. Patient Name Patient (Guardian) Signature) Relationship to Patient Date By submitting this form you agree to the above mentioned consent statement Submit Your request has been sent -- we will be in contact with you shortly. There was an error! Please phone our office.