• Perio Implant Health Professionals

    A Dental Practice

    Angel Emmanuel Rodriguez, DDS, CAGS, MSD, William Matoska, DDS. APDC, Joan Otomo-Corgel, DDS, MPH, FACD, APDC

    1127 Wilshire Blvd., Suite 1110, Los Angeles, CA 90017 Tel: (213) 481-0664 Fax: (213) 481-2902

    Dental Implants, Esthetic Regenerative Periodontics, Oral Medicine

  • Patient Information

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  • INSURANCE

  • To avoid misunderstanding regarding dental insurance, we wish our patients to know that ALL PROFESSIONAL SERVICES RENDERED are CHARGED DIRECTLY TO PATIENT and that PATIENTS ARE PERSONALLY RESPONSIBLE FOR PAYMENTS OF ALL FEES. We will prepare the necessary forms or reports to help you obtain your benefits from insurance companies. We do not render our services on the basis that insurance companies will pay our fees.

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  • MEDICAL HEALTH HISTORY

  • Periodontal disease is caused by a combination of complex factors and successful treatment depends upon their identification. Even though some of these question seem unrelated to your periodontal condition, they are all associated with proper oral health care. Please answer all questions. Circle yes or no, whichever applies. All answers are confidential.

     

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  • PLEASE INFORM THE DOCTOR IF YOUR HEALTH CHANGES IN ANY WAY

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  • I understand that where appropriate, credit bureau reports may be obtained.

  • Perio Implant Health Professionals

  • Primary Dental Insurance

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  • Secondary Dental Insurance (If Applicable):

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  • Assignment of Benefits:

    I understand that I am responsible for all costs associated with the dental treatment/ care rendered to me by Perio Implant Health Professionals. As a courtesy, Perio Implant Health Professionals will bill my dental insurance company to assist me with attaining any payable benefits. I hereby authorize payment of the dental benefits otherwise payable to me to be paid directly to Perio Implant Health Professionals.

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