Morrow & Gayheart - New Patient Form

  • Morrow & Gayheart

  • Health History Form

  • Date of Birth*
     - -

  • Your medical history is important to the treatment you will receive. Therefore, it is important that you respond to each question honestly and completely. Please enter/select your responses.

  • Please describe your current health*
  • Have there been any changes in your general health in the past year? *
  • Are you now under a physician’s care for a particular problem at this time? *
  • Have you ever been hospitalized or had a serious illness?*

  • PATIENT MEDICAL HISTORY

  • Rows
  • Congenital heart disease, cardiovascular disease (heart attack, heart murmur, coronary artery disease, chest pain, high/ low blood pressure, stroke, irregular heartbeat, heart surgery, pacemaker)? *
  • Implants placed anywhere in the body (heart valve, pacemaker, hip, knee)?*
  • Kidney disease or kidney failure, requiring dialysis? Y*
  • Thyroid disease?*
  • Stomach ulcers or colitis?*
  • Clicking, popping, or pain within the jaw joint and/or difficulty opening mouth?*
  • Frequent or recurring mouth sores?*
  • Radiation to the head or neck for cancer treatment?*
  • Glaucoma?*
  • Lung disease (asthma, emphysema, COPD, chronic cough, bronchitis, pneumonia, tuberculosis, shortness of breath, chest pain, severe coughing)? *
  • Bleeding disorder, anemia, bleeding tendency, blood transfusion? Do you bruise easily?*
  • Liver disease (jaundice, hepatitis A, B, or C)?*
  • Diabetes?*
  • Arthritis?*
  • Significant weight loss or gain?*
  • Seizures, convulsions, epilepsy, fainting or dizziness?*
  • Sinus or nasal problems?*
  • Osteoporosis or osteopenia?*
  • Any disease, chemotherapy or transplant operation? Cancer?*
  • Do you have any other disease, condition or problem NOT listed above that you think the doctor should know about?*

  • FAMILY MEDICAL HISTORY

  • Rows
  • Diabetes? *
  • Cancer?*
  • Heart disease?*
  • Bleeding problems?*
  • Tumors?*
  • Lung disease?*

  • FEMALE PATIENTS

  • Are you pregnant, or is there any chance you might be pregnant?
  • Date of Birth*
     - -

  • MEDICATIONS

  • Rows
  • Antibiotics?*
  • Aspirin or drugs such as Motrin, Aleve, Ibuprofen?*
  • Anticoagulants (blood thinners)?*
  • Insulin or oral anti-diabetic drugs?*
  • Heart drugs?*
  • High blood pressure medications? Y*
  • Steroids (cortisone, prednisone, etc.)? antianxiety agents, sedative-hypnotics and antidepressants*
  • Prescription pain medication?*
  • Bisphosphonates, antiangeogenic and/or antiresorptive medications for osteoporosis, multiple myeloma or other cancers?*

  • PHARMACY INFORMATION

  • ALLERGIES

  • Rows
  • Latex?*
  • Codeine or other pain killers?*
  • Food products?*
  • Aspirin, Motrin, Aleve, or ibuprofen?*
  • Sedatives, barbiturates?*
  • Penicillin or other antibiotics?*
  • Have you or an immediate family member had any problem associated with local anesthesia, general anesthesia, and/or intravenous sedation?*

  • SOCIAL HISTORY

  • Have you ever smoked or chewed tobacco?*

  • Have you ever sought professional care or been hospitalized for:

  • Drug abuse? *
  • Emotional disorders?*
  • Alcoholism?*

  • Do you use:

  • Alcohol?*
  • Marijuana?*
  • Recreational drugs?*

  • DENTAL HISTORY

  • Have you had any adverse effects from dental treatment?*
  • Do you wish to talk to the doctor privately about anything?*

  • I understand the importance of a truthful and complete health history to assist my doctor in providing the best care possible. To the best of my knowledge, the above information is complete and correct.

  • Date *
     - -

  • Patient Agreement

  • Limitation of Practice:
    Patient understands that Drs. Morrow & Gayheart’s practice is limited to Oral and Maxillofacial Surgery.

    Patient Consent:
    Patient hereby gives my consent, if needed, for drawing blood samples for diagnosis or in case of accidental puncture of exposure to medical personnel during my course of treatment either in the offices or in the hospital. These tests may include AIDS testing.

    Insurance Claims Filing:
    In all cases, the patient is responsible for payment of their account. As a courtesy, Morrow & Gayheart will file a claim to the patient’s insurance carrier.

    Assignment and Release:
    Patient hereby authorizes and assigns applicable insurance benefits to be paid directly to the physician. Patient is financially responsible for non-covered services. Patient authorizes release of information necessary to process insurance claims. Patient authorizes photographs, diagnostic dental models restricted for medical, dental, education or insurance purposes and information release to other practitioners in good faith effort for my medical care. Patient authorizes disclosure of medical record information to JCAHO surveyor in connection with performance of his/her duties as a surveyor.

    Deductibles/Co-payments:
    Payment of your deductible as well as an estimate of your share (co-payment) of the fee is due at the time services are rendered. Payments can be made in the form of cash, check, Visa, MasterCard or Care Credit. If the insurance pays more or less than the estimated amount you will be billed or reimbursed accordingly. Patient balances are due 30 days after insurance coverage payment has been made.

    Unpaid Balances:
    If, for any reason, the patient cannot make scheduled payments, the patient must immediately contact the office of Morrow & Gayheart to make acceptable arrangements. Drs. Morrow and Gayheart reserve the right to refer all unpaid accounts to collection agencies. Any fees associated with collection, including collection agency contingency fees and/or court costs, will be added to the patients account balance. After accounts are placed with collection agencies all patient visits and procedures will be conducted on a cash only basis.

    Service Charge:
    • Drs. Morrow and Gayheart reserve the right to assess a service charge, not to succeed $20.00 per month, to a patient account for any unpaid balance over 30 days after the insurance coverage has been paid.
    • A 2% credit card processing surcharge will be applied to all credit card payments.
    • Patients whose Ins companies utilize the 3rd party payer ZELIS will also be subject 2% surcharge.

    Health Information Privacy Policies and Procedures:
    In compliance with the Health Insurance Portability and Accountability Act of 1996 (HIPAA), I acknowledge that I have been informed of the Privacy Policies and Procedures of Morrow & Gayheart, PLLC. (We have a copy at the front desk.) I understand that I may obtain a copy of these procedures from the receptionist at the front desk upon request.

  • Patient Insurance Information

    Welcome to our office. So that we may assist you in filing your dental/health insurance forms, please provide us with the information requested below. All information is kept confidential.
  • Sex*
  • DOB*
     - -

  • Name of Person Responsible for Account

  • DOB
     - -

  • Dental Insurance Plan

  • DOB
     - -

  • Medical Insurance Plan

  • DOB
     - -

  • ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES**

    You may refuse to sign this acknowledgement**

  • I * have received a copy of this office’s Notice of Privacy Practices.

  • Date*
     - -

  • I understand that in order for information to be disclosed to anyone other than myself, I must give permission to Nick S. Morrow, D.M.D., or Matthew N. Gayheart, D.M.D., M.D.

    I give permissions for Nick S. Morrow, D.M.D., or Matthew Gayheart, D.M.D., M.D., to discuss information regarding my care/treatment/account to the following listed persons. (Please Print Names of All that apply.)

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