Jenkins, Morrow & Gayheart

Patient’s Name*

Date of Birth*

Date

Gender*

Height

Weight

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*

ExcellentGoodFairPoor

Please describe the symptoms you are currently having today

Have there been any changes in your general health in the past year? *

YesNo

If yes, please describe

Are you now under a physician’s care for a particular problem at this time? *

YesNo

If yes, please describe

Have you ever been hospitalized or had a serious illness?*

YesNo

If yes, please describe

Do you have or have you ever had

	Yes	No
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
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

Congenital heart disease, cardiovascular disease (heart attack, heart murmur, coronary artery disease, chest pain, high/ low blood pressure, stroke, irregular heartbeat, heart surgery, pacemaker)? *

YesNo

Implants placed anywhere in the body (heart valve, pacemaker, hip, knee)?*

YesNo

Kidney disease or kidney failure, requiring dialysis? Y*

YesNo

Thyroid disease?*

YesNo

Stomach ulcers or colitis?*

YesNo

Clicking, popping, or pain within the jaw joint and/or difficulty opening mouth?*

YesNo

Frequent or recurring mouth sores?*

YesNo

Radiation to the head or neck for cancer treatment?*

YesNo

Glaucoma?*

YesNo

Lung disease (asthma, emphysema, COPD, chronic cough, bronchitis, pneumonia, tuberculosis, shortness of breath, chest pain, severe coughing)? *

YesNo

Bleeding disorder, anemia, bleeding tendency, blood transfusion? Do you bruise easily?*

YesNo

Liver disease (jaundice, hepatitis A, B, or C)?*

YesNo

Diabetes?*

YesNo

Arthritis?*

YesNo

Significant weight loss or gain?*

YesNo

Seizures, convulsions, epilepsy, fainting or dizziness?*

YesNo

Sinus or nasal problems?*

YesNo

Osteoporosis or osteopenia?*

YesNo

Any disease, chemotherapy or transplant operation? Cancer?*

YesNo

If so, where?

When was the date of your last treatment?

Do you have any other disease, condition or problem NOT listed above that you think the doctor should know about?*

YesNo

If yes, please explain

Do you have a family history of any of the following? If yes, indicate the relationship.

	Yes	No	Relationship
Diabetes
Cancer
Heart disease
Bleeding problems
Tumors
Lung disease

Diabetes? *

YesNo

Relationship

Cancer?*

YesNo

Relationship

Heart disease?*

YesNo

Relationship

Bleeding problems?*

YesNo

Relationship

Tumors?*

YesNo

Relationship

Lung disease?*

YesNo

Relationship

Are you pregnant, or is there any chance you might be pregnant?

YesNo

Patient Name

First NameLast Name

Date of Birth*

Date

Are you using any of the following

	Yes	No
Antibiotics
Aspirin or drugs such as Motrin, Aleve, Ibuprofen
Anticoagulants (blood thinners)
Insulin or oral anti-diabetic drugs
Heart drugs
High blood pressure medications
Steroids (cortisone, prednisone, etc.) antianxiety agents, sedative-hypnotics and antidepressants
Prescription pain medication

Antibiotics?*

YesNo

Aspirin or drugs such as Motrin, Aleve, Ibuprofen?*

YesNo

Anticoagulants (blood thinners)?*

YesNo

Insulin or oral anti-diabetic drugs?*

YesNo

Heart drugs?*

YesNo

High blood pressure medications? Y*

YesNo

Steroids (cortisone, prednisone, etc.)? antianxiety agents, sedative-hypnotics and antidepressants*

YesNo

Prescription pain medication?*

YesNo

Bisphosphonates, antiangeogenic and/or antiresorptive medications for osteoporosis, multiple myeloma or other cancers?*

YesNo

If yes, list drugs used and time of use.

Please list any other medications you have taken or are currently taking not listed above including prescription medications, diet drugs, over the counter medications, herbal or holistic remedies, vitamins or minerals:

Pharmacy Name*

Pharmacy Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Are you allergic to or have you had an adverse reaction to

	Yes	No
Latex
Codeine or other pain killers
Food products
Aspirin, Motrin, Aleve, or ibuprofen
Sedatives, barbiturates
Penicillin or other antibiotics

Latex?*

YesNo

Codeine or other pain killers?*

YesNo

Food products?*

YesNo

Aspirin, Motrin, Aleve, or ibuprofen?*

YesNo

Sedatives, barbiturates?*

YesNo

Penicillin or other antibiotics?*

YesNo

Have you or an immediate family member had any problem associated with local anesthesia, general anesthesia, and/or intravenous sedation?*

YesNo

If yes, which anesthetic?

Relationship?

Other drug allergies not listed above

Have you ever smoked or chewed tobacco?*

YesNo

If yes, for how long?

Drug abuse? *

YesNo

Emotional disorders?*

YesNo

Alcoholism?*

YesNo

Alcohol?*

YesNo

How often?

Marijuana?*

YesNo

How often?

Recreational drugs?*

YesNo

How often?

Have you had any adverse effects from dental treatment?*

YesNo

If Yes, please explain?

Do you wish to talk to the doctor privately about anything?*

YesNo

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.

Signature of patient, parent, guardian *

Printed name of patient, parent, guardian/Relationship *

Date *

Date

Limitation of Practice:
Patient understands that Drs. Jenkins, Dr. Morrow’s & Dr. 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, Jenkins, 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 Jenkins, Morrow & Gayheart to make acceptable arrangements. Drs. Jenkins, 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. Jenkins, 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 Jenkins, 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 Name (Print Name) *

Patient/Parent/Guardian Signature *

First Name*

Middle Initial

Last Name*

Sex*

MaleFemale

Age*

DOB*

Date

Soc. Sec #*

Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code

Cell #

Email

example@example.com

Name

Relationship

SS#

DOB

Date

Billing Address

Home Phone#:

Work#:

Cell#:

Name of Dental Insurance Plan

Group #

ID #

Subscriber’s Name

Subscriber’s Employer

Subscriber’s Soc. Sec. #

DOB

Date

Relationship to Subscriber

Name of Medical Insurance Plan

Group #

ID #

Subscriber’s Name

Subscriber’s Employer

Soc. Sec. #

DOB

Date

Relationship to Subscriber

Referring Dentist/Orthodontist/Physician

Reason for Visit

Emergency Contact Name*

Relationship*

Home Phone

Work Phone

Cell Phone

I (Print Patient Name) * have received a copy of this office’s Notice of Privacy Practices.

Patient Signature or Parent/Guardian Signature *

Date*

Date

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

I give permissions for W. Scott Jenkins D.M.D., M.D., 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.)

Parent/Guardian Name

Spouse/Partner Name

Referring Dentist/Doctor Name

Friend Name

Brother/Sister Name/s

Child/Children Name

Other

Do not release or discuss my information with the following listed persons:

Health History Form

PATIENT MEDICAL HISTORY

FAMILY MEDICAL HISTORY

FEMALE PATIENTS

MEDICATIONS

PHARMACY INFORMATION

ALLERGIES

SOCIAL HISTORY

Have you ever sought professional care or been hospitalized for:

Do you use:

DENTAL HISTORY

Patient Agreement

Patient Insurance Information

Name of Person Responsible for Account

Dental Insurance Plan

Medical Insurance Plan

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES**