New Patient - St. Matthew’s OMS

New Patient Form
Office Location
PATIENT'S FULL NAME:
DATE OF BIRTH:

MonthDayYear
Date
PATIENT'S ADDRESS:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PATIENT'S HOME PHONE:
Please enter a valid phone number.
CELL PHONE:
Please enter a valid phone number.
WORK PHONE:
Please enter a valid phone number.
PATIENT'S AGE:

MonthDayYear
Date
PATIENT'S MARITAL STATUS (PLEASE CIRCLE)

SINGLEMARRIEDDIVORCEDWIDOWED
PERSON RESPONSIBLE FOR THIS ACCOUNT (IF OTHER THAN PATIENT)
PATIENT/PARENT EMPLOYER:
SPOUSE'S NAME:
SPOUSE'S NAME:
EMPLOYER:
WORK PHONE:
Please enter a valid phone number.
DO YOU HAVE DENTAL INSURANCE?

YesNo
DO YOU HAVE MEDICAL INSURANCE?

YesNo
IF YES, COMPLETE THE INSURANCE INFORMATION LISTED BELOW:
CARDHOLDER'S NAME OTHER THAN PATIENT)
DATE OF BIRTH:

MonthDayYear
Date
CARDHOLDER'S EMPLOYER:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
INSURANCE COMPANY NAME:
GROUP#:
Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
PHARMACY NAME:
PHARMACY PHONE#:
Please enter a valid phone number.
REFERRED BY:
NAME OF DENTIST:
NAME OF PHYSICIAN:
EMERGENCY CONTACT:
Please enter a valid phone number.
HOME PHONE (OTHER THAN PATIENT'S):
Please enter a valid phone number.
WORK #:
Please enter a valid phone number.

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES
IT IS OKAY TO SPEAK WITH REGARDING MY TREATMENT AND ACCOUNT
I , HAVE RECEIVED A COPY OF THIS OFFICE'S NOTICE OF PRIVACY PRACTICES.
Signature

Clear
DATE

MonthDayYear
Date
OK TO TEXT

OFFICE FINANCIAL POLICY
It is the policy of this office to make complete payment arrangements at the time of the office visit. This may be handled in one of the following ways:
1. If you are here for a consultation, payment for the office visit and any x-rays is expected today. The fee for any indicated surgery will be discussed with you.
2. If you have dental insurance, or medical insurance that covers Oral Surgery, your portion of charges (the co-payment) is expected at the time services are performed. We will call your insurance company to verify your coverage and collect information regarding your anticipated coverage benefits. We will refund any overpayment to you or send you a bill for any underpayment.
3. If you do not have dental insurance, payment in full is expected at the time of surgery, unless prior arrangements are made with the office manager. In addition to cash and checks, we also accept Visa and Mastercard, or other monthly payment options.
4. We welcome and encourage frank discussion of services and fees prior to treatment in order to avoid misunderstandings.
This is to certify that I, , accept full responsibility for all charges incurred by (patient) for diagnostic/surgical treatments performed by OMS of Louisville , as is necessary in their judgement.
All amounts not paid within ninety (90) days after the day of treatment will be considered in default and subject to certain deliquency charges, which I agree to pay. It is understood by me that the deliquency charges will be computed by applying a rate of one (1) percent per month, which is an annual rate of twelve (12) percent, to the unpaid balance beginning ninety (90) days after treatment, until paid. It is understood by me that should my account be turned over for collection, then I will be responsible for collection costs, including reasonable attorney's fees.

**** I authorize release of all medical/dental records necessary to process an insurance claim and hereby assign benefits to OMS of Louisville.
Signature:

Clear
Date:

MonthDayYear
Date
Should be Empty:

	Yes	No
A Heart Ailment (murmur, angina, heart attack, heart failure, rhythm problems)
Rheumatic Fever
High Blood Pressure
Lung Disease / TB
Asthma
Bronchitis
Liver Disease / Hepatitis
Tumors, Growths or Cancer
Nervous or Psychiatric Disorders
Sinus, Nasal or Ear Disease
Osteoporosis
Seizure Disorder
Arthritis
Thyroid Disease
Blood Disease
Diabetes
Glaucoma
Stomach or Intestinal Disease
Kidney Disease
Illicit Drug Abuse
HIV infection or AIDS

New Patient Form

IF YES, COMPLETE THE INSURANCE INFORMATION LISTED BELOW:

ACKNOWLEDGEMENT OF RECEIPT OF NOTICE OF PRIVACY PRACTICES

HEALTH HISTORY

OFFICE FINANCIAL POLICY