Prestige Oral and Facial Surgery Form Packet

Doctor Signature

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COVID-19 PANDEMIC - PATIENT DISCLOSURES
This patient disclosure form seeks information from you that we must consider before making treatment decisions in the

circumstance of the COVID-19 virus.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition), can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.
Do you have a fever or above-normal temperature?*

yesnoo
Have you experienced shortness of breath or had trouble breathing?*

yesno
DO you have a dry cough*

yesno
DO you have a runny nose*

yesno
Have you recently lost or had a reduction in your sense of smell?*

yesno
Do you have a sore throat?*

yesno
Have you been in contact with someone who has tested positive for COVID-19?*

yesno
Have you tested positive for COVID-19?*

yesno
Have you been tested for COVID-19 and are awaiting results?*

yesno
Have you traveled outside the United States by air or cruise ship in the past 14days?*

yesno
Have you traveled within the United States by air, bus or train within the past 14days?*

yesno2
l fully understand and acknowledge the above information, risks and cautions regarding a compromised immune system and have
disclosed to my provider any conditions in my health history which may result in a compromised immune system.

By signing this document, I acknowledge that the answers I have provided above are true and accurate.
Signature*

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Date*

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Date
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COVID-19 PANDEMIC EMERGENCY DENTAL TREATMENT NOTICE AND ACKNOWLEDGEMENT OF RISK FORM
Our goal is to provide a safe environment for our patients and staff, and to advance the safety of our local community. This document provides information we ask you to acknowledge and understand regarding the COVID-19 virus.

The COVID-19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID-19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting

COVID-19 associated with dental care.

The COVID-19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID-19 is challenging and complicated due to limited availability for

Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office.

Dental procedures create water spray which is one way the disease is spread. The ultra-fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID-19 virus to those nearby.

You cannot wear a protective mask over your mouth to prevent infection during treatment as your health care providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.

Pursuant to statements from the Center for Disease Control (CDC) and the American Dental Association (ADA), nonessential or elective treatment, based on the assessment of our staff, will be rescheduled. According to the ADA, dental emergencies are "potentially life threatening and require immediate treatment to stop ongoing tissue bleeding [or to] alleviate severe pain or infection." The ADA also recommends that urgent dental care which "focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments" be provided in as minimally invasive a manner as possible.

Iconfirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID-19 virus in the dental office or with dental treatment. I further confirm I am seeking treatment for a condition that meets the emergent or urgent criteria noted above. I understand and accept the additional risk of contracting COVID-19 from contact at this office. I also acknowledge that I could contract the COVID-19 virus from outside this office and unrelated to my visit here.

I have read and understand the information stated above:
Signature*

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Date*

MonthDayYear
Date
Witness
Pharmacy Information
Patient Name*
DOB*
Pharmacy name*
Pharmacy Address
Pharmacy Phone Number
REGISTRATION FORM
Patient Information
Date*

MonthDayYear
Date
Name*

First NameMiddle InitialLast Name
Date of Birth*

MonthDayYear
Date
Please select one*

marriedsingledivorced
Patient Social Security #*
Phone Number*
Mailing Address *

Mailing Address

Street Address Line 2

CityState / Province

Postal / Zip Code
St*
Zip*
Email*
example@example.com
Employer*
How Long Employed*
Student
Full Time
Address*

Billing Address

Street Address Line 2

CityState / Province

Postal / Zip Code
St*
Zip*
Responsible Party
Name

First NameLast Name
Date of Birth

MonthDayYear
Date
Driver License No
Relationship to Patient
SS
Primary Dental Insurance
Subscriber's Name
Sub DOB
Sub ID/SS
Name of Insurance
Insurance Address
Insurance Phone
Group Name/Number
Secondary Dental Insurance
Subscriber's Name
Sub DOB
Sub ID/SS
Name of Insurance
Insurance Address
Insurance Phone
Group Name/Number
Medical Insurnace
Subscriber's Name
Sub DOB
Sub ID/SS
Name of Insurance
Insurance Address
Insurance Phone
Group Name/Number
The above information is true to the best of my knowledge. I authorize my insurance benefits be paid directly to the physician. i understand that i am financially responsible for any balance I also authorize [Name of Practice] or insurance company to release any information required to process my claims.
Emergency Contact
Name*
Relationship to patient*
Home phone no.
Work phone no.
MEDICAL HISTORY FORM
Date*

MonthDayYear
Date
Name*
Date of Birth*

MonthDayYear
Date
Sex:*

malefemale
Height*
Weight*
FOR THE FOLLOWING QUESTIONS, CIRCLE YES OR NO, WHICHEVER APPLIES. YOUR ANSWERS ARE FOR OUR RECORDS ONLY AND WILL BE KEPT CONFIDENTIAL.
1. Are you in good health?*

yesno
2. Has there been any change in your health in the past year?*

yesno
3. My last physical exam was on:*
Please add date or year
4. Are you now under the care of a physician?*

yesno
If so, for what condition?*
5. The name and address of my physician is*
6. Have you had any serious illness, operation or hospitalization within the past 5 years?*

yesno
7. Have you had an artificial joint replacement (knee, hip, shoulder, etc.)?*

yesno
8. Are you taking or have you ever taken Bisphoshonates for osteoporosis or chemotherapy for multiple myeloma or other cancers (Reclast, Fosamax, Actone, Boniva, Aredia, Zometa or Prolia)?*

yesno
9. Are you taking any medicine(s) including diet pills, non prescription, vitamins, homeopathic or natural remedies?*

yesno
If so, please list
Do you Have any of these problems?
a. Damaged heart valves, artificial valves or heart murmur*

yesno
b. Rheumatic Heart Disease
b. Rheumatic Heart Disease*

yesno
Heart trouble, heart attack, angina, high blood pressure, stroke, arleriosclerosisor any other Heart conditions?*

yesno
1. Chest pain upon exertion?*

yesno
2. Shortness of breath after mild exercise?*

yesno
3. Do your ankles swell?
3. Do your ankles swell?*

yesno
Allergies*

yesno
Sinus Trouble*

yesno
Asthma or Hay fever?*

yesno
Fainting spells or seizures*

yesno
Diabetes*

yesno
Hepatitis, jaundice, or liver disease?*

yesno
Frequent or recurring mouth sores*

yesno
k. Thyroid problems*

yesno
I. Respiratory problems, emphysema, bronchitis, etc*

yesno
m. Arthritis or painful, swollen joints including jaw joint (TMJ)*

yesno
n. Osteoporosis*

yesno
O. Stomach Ulcer or hyperacidity*

yesno
p. Kidney trouble*

yesno
q. Tuberculosis*

yesno
r. Persistent cough or cough that produces blood*

yesno
S. Persistent swollen neck glands*

yesno
t. Low blood pressure*

yesno
u. Epilepsy or neurological disorder*

yesno
Cancer*

yesno
W. Any disease, drug or transplant operation that has depressed your immune system*

yesno
MEDICAL HISTORY FORM

Continued...
11. Have you had abnormal bleeding?*

yesno
a. Have you ever required a blood transfusion?*

yesno
12. Do you have any blood disorders such as anemia?*

yesno
13. Have you ever had treatment for a tumor or growth?*

yesno
14. Have you had radiation therapy to the head, neck or jaws?*

yesno
Are you allergic to or have you had a reaction to:
a. Local Anesthetics*

yesno
b. Penicillin or Antibiotics*

yesno
C. Sulfa Drugs*

yesno
d. Barbiturates or Sleeping Pills*

yesno
e. Aspirin*

yesno
f. lodine*

yesno
g. Codeine or Other Narcotics*

yesno
h. Latex or Rubber Products*

yesno
i. other*

yesno
16. Have you had any serious trouble associated with previous dental treatment?*

yesno
If so, explain
17. Do you have any other condition or disease you thing the doctor should know about?*

yesno
If so, explain
18. Do you smoke or chew Tobacco?*

yesno
How much?
19. Is there any past history of alcohol or chemical dependency or emotional disorder that may affect the care we provide you?*

yesno
20. Are you wearing contact lenses?*

yesno
21. Are you wearing removable dental appliances?*

yesno
22.Do you wish to talk with the doctor privately about anything?*

yesno
Women
23. Are you pregnant or trying to become preqnant*

yesno
24. Do you have problems associated with your menstrual period?*

yesno
25. Are you nursing?*

yesno
26. Are you taking birth control pills?*

yesno
27. Last menstrual period?
What is the main reason for your visit?
I authorize my surgeon and his/her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthemore, I authorize the taking of all X-Ray required as a necessary part of this examina- tion. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers.

I have read and understand the above. Any questions I had about this form have been answered and I understand the answers. I understand it is my responsibility to fill out the form correctly and completely.
Name of Patient
Sign*

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Date*

MonthDayYear
Date
Name of Parent/Guardian
Sign

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Date

MonthDayYear
Date
PRESTIGE ORAL & FACIAL SURGERY CENTER
PATIENT PRIVACY FORM
Patient's Name*
This form is optional under the new patient privacy regulations recently issued by the United States Department of health and Human Services. We have elected to use this form, prior to begin your treat This Notice of Privacy Practices provides information about how we may use and disclose protected health information about you. It 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. Your protected health information (i,e., names, dates, phones numbers, email address, home address, social security, etc may be used in connection with your treatment, payment of your account or health care operations. 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 (HIPAA

as a patient or patient's guardian in Prestige Oral and Facial Surgery Center, authorize the medical information regarding my treatment and care to be discussed with the following individuals.
I, as a patient or patient's guardian in Prestige Oral and Facial Surgery Center, authorize the medical information regarding my treatment and care to be discussed with the following individuals.*
Name of Patient*
Sign*

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Date*

MonthDayYear
Date
Authorized Recipient
Sign

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Date

MonthDayYear
Date
OFFICE POLICY AND FINANCIAL AGREEMENT
We appreciate that you have chosen our office as your health provider. For the convenience of our patients, we have established an office policy and financial agreement for review.

As a service to our patients, we will be in the best position to present electronic claims as a courtesy to your insurance. We may not be a participating provider in your insurance plan. This means that you are responsible for the difference between our rate and the allowed insurance rate. We work with your insurance company to provide you with the most accurate estimate of your co-payments. It is the patient's responsibility to provide the correct insurance information at the first visit. Payment is required at the time of service for all uninsured patients. Insured patients are responsible and must be prepared to pay all amounts that are not covered by the insurance estimate. With insurance plans paying only part of the cost of treatment, we can only estimate what your insurance company will pay. The maximum time allowed for an insurance payment is sixty (60) days. After sixty days, the patient is responsible for the entire balance. We work to help you receive the maximum benefits available under your policy, but we will not be responsible for how your insurance company handles your claims or what benefits you pay in a claim; At no time do we guarantee what your insurance will or will not do with each claim.

We accept Visa, Mastercard, Discover, American Express, and JCB. We offer these to allow you the greatest convenience in the care of your account. Payment plans We have decided with Care Credit Company to provide payment plans. This allows you to complete your treatment without delay and make relatively small monthly payments. Credit requests for assistance are available, and approval can be determined in ten minutes. For your convenience, you can submit your application online at www.carecredit.com

Cancellations As a courtesy to all patients, we request that a forty-eight (48) hour notice be given for a canceled appointment. If we have not received sufficient notice, a charge may apply to your account.
DISCLOSURE OF INFORMATION AND ALLOCATION OF BENEFITS
The undersigned in this agreement read the foregoing and accept, whether signed as a responsible or as a patient, to pay our practice full professional fees without regard to insurance coverage. He/She also agree to pay interest on any balance for 90 days from the date of service. In addition, you agree to pay the collection fees, attorneys' fees and court costs in case these means of collection are required.

The undersigned agrees to allow Prestige Oral and Facial Surgery Center to disclose any information requested by the insurance company and to use patient photos (retaining all names) as educational tools within our practice.
Signature of the patient or legal guardian of a minor*

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Date*

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COVID-19 PANDEMIC - PATIENT DISCLOSURES

COVID-19 PANDEMIC EMERGENCY DENTAL TREATMENT NOTICE AND ACKNOWLEDGEMENT OF RISK FORM

REGISTRATION FORM

MEDICAL HISTORY FORM

MEDICAL HISTORY FORM

PRESTIGE ORAL & FACIAL SURGERY CENTER

PATIENT PRIVACY FORM

OFFICE POLICY AND FINANCIAL AGREEMENT

DISCLOSURE OF INFORMATION AND ALLOCATION OF BENEFITS