New Patient Registration

CENTRAL WASHINGTON
Jeremiah Johnson DDS, MD Tyler McDonald DDS Brenen Olsen, DDS
PATIENT INFORMATION
Patient Name
Birthdate

MonthDayYear
Date
Gender
Preferred Name
Social Securty Number
Home Phone
Cell Phone
Employer
Position
Address

Address

Street Address Line 2

CityState

Zip code
Email
example@example.com
Can we use email for important information?*

YesNo
Emergency contact
Relation
Phone
Preferred Pharmacy
Address
Phone
REFERRAL INFORMATION
Dentist
Location
Orthodontist
Medical Doctor
Other Doctor
GUARDIAN INFORMATION
Guardian Name
Birthdate

MonthDayYear
Date
Social Security Number
Employer
Position
Phone
Address

Address if different

Street Address Line 2

CityState

Zip code
Email
example@example.com
Can we use email for important information?*

YesNo
INSURANCE AND PAYMENT INFORMATION
Who is responsible for the bill?

SelfGuardianOther
Subscriber Name
Social Security Number
Birthdate

MonthDayYear
Date
Insurance Company
Group Name
ID
Employer
Subscriber Name
Social Security Number
Birthdate

MonthDayYear
Date
Insurance Company
Group Name
ID
Employer
Subscriber Name
Social Security Number
Birthdate

MonthDayYear
Date
Insurance Company
Group Name
ID
Employer
Subscriber Name
Social Security Number
Birthdate

MonthDayYear
Date
Insurance Company
Group Name
ID
Employer
Patient or Guardian Signature*

Clear
Date

MonthDayYear
Date
Jeremiah Johnson DDS, MD Tyler McDonald DDS Brenen Olsen, DDS
CENTRAL WASHINGTON
Additional Disclosure Authorization

In addition to the allowable disclosures described in the Statement of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. I understand that by not indicating "YES" in the answer to each individual question, the default answer is "NO," and my Protected Healthcare Information (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.

Name of Patient: (please print)
Name

FIRST NAMELAST NAME
Date

MonthDayYear
Date
Any relative (e.g., Spouse, Children, Children's Spouses, etc Name of person(s) authorized to receive confidential information:
Other
In addition to the allowable disclosures described in the Statement of Privacy Practices, and as noted above, Igive permission for the offices of Central Washington Oral & Facial Surgery to leave detailed messages regarding upcoming appointments including dates, times, pre and post-operative instructions, and any medications needed.

On my home phone On my cellular phone
Patient or Legal Guardian Signature*

Clear
Relationship to Patient
Jeremiah Johnson DDS, MD Tyler McDonald DDS Brenen Olsen, DDS
CENTRAL WASHINGTON
Patient Name
What brings you in today
Do you see a medical doctor? Have there been any changes in your general health in the past year?
If yes for what
Do you have pain in the jaw, TMJ, or face? Have you had a serious illness or hospitalization within the last five years?
If yes please list
Please list any surgeries
Do you have joint replacements?

YesNo
Do you take antibiotics before dental treatment?

YesNo
Has anesthesia affected you or your family?

YesNo
Have you taken bisphosphonates like Fosamax6 in the past?

YesNo
NOTE: These medications can lead to medication-related osteonecrosis of the jaws that may interfere with normal healing after surgery.
ALLERGIES: Please list any known allergies:
What was the reaction
Please list all medications you are currently taking
Herbal Supplements
DO YOU CURRENTLY:
IN THE PAST?
Use Marijuana Use Other Drugs REVIEW OF SYSTEMS: Check all that apply. Heart Valve or Vascular Problems High Blood Pressure Heart Attack Stroke Blood Thinner or Bleeding Tendency Malignant Hyperthermia Irregular Heart Beat (A-Fib) Breathing or Lung Problems Asthma

COPD or Emphysema Obstructive Sleep Apnea Use CPAP Osteoporosis Liver Problems Bleed Easily Hepatitis Jaundice

Thyroid Disease Kidney Problems Dialysis Cancer Radiation or Chemotherapy Neurologic or Mood Problems Depression or Anxiety Seizures Neurologic Disorder (e.g., Parkinson's)
WOMEN ONLY:
YesNo Could you be or are you planning to be pregnant? Do you use birth control? NOTE: Antibiotics can interfere with contraceptives. Alternative or additional methods must be used when taking these medications to prevent pregnancy.
Jeremiah Johnson DDS, MD Tyler McDonald DDS Brenen Olsen, DDS
CENTRALWASHINGTON
Our main goal at Central Washington Oral & Facial Surgery (CWOFS) is to help take good care of you. We deliver the finest care at the most reasonable cost to our patients; therefore, payment is due at the time service is rendered, unless other arrangements have been made in advance. As a courtesy, CWOFS will bill your insurance company. We do our best to estimate in advance what they will contribute toward the cost of your procedure and to maximize the benefits available to you. Please understand that your insurance benefits are a contract between yourself and your insurance carrier. You are responsible for all charges regardless of any insurance payment and dispute. Any treatment, deductibles, or copays not covered by your insurance are your responsibility on the Initial day of service.
Initial*
Estimates are not a guarantee of payment. If your insurance company doesn't pay as estimated, remaining balance will be due in full 30 days following receipt of statement. If they pay more, you will receive a refund.
Initial*
Finance Charges of 1% per month will be applied to balances over 31 days old.
Initial*
Wisdom Teeth treatments require a $100 deposit in advance to reserve the length of time necessary for your procedure. Most surgeries will require 50% deposit of total out of pocket at the time of scheduling and 50% due at the time of check in.
Initial*
For patients without insurance, we collect in full at the time of service. We offer a 5% discount when payment is made in the form of cash or a check. Credit and debit cards are not consideredcash payment. An additional 3.5% processing fee will be charged for all card transactions.
Initial*
For your convenience, we accept Visa, MasterCard, Discover, American Express, cash, or check. (A $40 NSF fee will be assessed for all returned checks We also are contracted with Care Credit and

can offer you 6-12-month interest free financing if qualified.
Initial*
If you need to cancel or reschedule your appointment, please provide 48 hours notice. Failure todo so will result in a $25 late cancellation/rescheduling fee.
Patient or Guardian Signature*

Clear
Date*

MonthDayYear
Date
Should be Empty:

CENTRAL WASHINGTON

PATIENT INFORMATION

REFERRAL INFORMATION

GUARDIAN INFORMATION

INSURANCE AND PAYMENT INFORMATION

CENTRAL WASHINGTON

CENTRAL WASHINGTON

DO YOU CURRENTLY:

IN THE PAST?

WOMEN ONLY:

CENTRALWASHINGTON