CENTRAL WASHINGTON

CENTRAL WASHINGTON
Jeremiah Johnson DDS, MD Tyler McDonald DDS

Brenen Olsen, DDS Brian Christensen DDS, MD
PATIENT INFORMATION
Patient Name:
Birthdate:

MonthDayYear
Date
Gender:
Preferred Name:
Social Security:
Home Phone:
Cell Phone:
Employer:
Position:
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 (If self referred N/A): *
Location:
Orthodontist:
Medical Doctor:
Other Doctor:
GUARDIAN INFORMATION
Guardian Name:
Birthdate:

MonthDayYear
Date
Social Security:
Employer:
Position:
Phone:
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:
Birthdate:

MonthDayYear
Insurance Company:
Group Name:
ID:
Employer:
Subscriber Name:
Social Security:
Birthdate:

MonthDayYear
Insurance Company:
Group Name:
ID:
Employer:
Subscriber Name:
Social Security:
Birthdate:

MonthDayYear
Insurance Company:
Group Name:
ID:
Employer:
Subscriber Name:
Social Security:
Birthdate:

MonthDayYear
Insurance Company:
Group Name:
ID:
Employer:
Patient or Guardian Signature:

Clear
Date

MonthDayYear
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:

FIRST NAMELAST NAME
Date

MonthDayYear
Any relative (e.g., spouse, children's spouses, ect. Name of the person (s) authorized to receive confidential information.

YesNoOther
In addition to the allowable disclosures described in the State of Privacy Practices and as noted above, I give 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.

YesNo
On home phone:

YesNo
Patient or Legal Guardian Signature:

Clear
Relationship to Patient:
Healthy History:
Patient Name:
What brings you in today:
Do you see a medical doctor?

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

YesNo
If yes, for what?
Do you have pain in the jaw, TMJ, or face?

YesNo
Have you had a serious illness or hospitalization within the last five years?

YesNo
If yes please list:
Please list any surgeries:
Do you have joint replacement?

YesNo
Do you take antibiotics before dental treatment?

YesNo
Has anesthesia affected you or your family?

YesNO
Have you taken bisphosphonates like Fosmax 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 know allergies:
What was the reaction?
Medications: Please list all medications you are currently taking:
Herbal Supplements
Do you Currently:

Use TobaccoDrink alcoholUse MarijuanaUse other drugs
Have you in the past?

Used TobaccoDrink AlcoholUse MarijuanaUse Other Drugs
REVIEW OF SYSTEMS: Check all that apply.

Heart Valve or Vascular PrombelmsHigh Blood PressureHeart AttackStrokeBlood thinner or Bleeding TendencyMalignant HyperthermiaIrregular HeartBeat (A-FIB)Breathing or Lung ProblemsAsthmaPneumoniaCOPD or EmphysemaObstructive Sleep ApneaUse CPAPOsteoporosisLiver ProblemsBleeds EasilyHepatitisJaundiceDiabetesThyroid DiseaseKidney ProblemsDialysisCancerRadiation or ChemotherapyNeurologic or Mood ProblemsDepression or AnxietySeizuresNeurologic Disorder (e.g. Parkinsons)
Women Only:
Could you be or are you planning to be pregnant?

YesNo
Do you use birth control?

YesNo
Financial Statement:
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 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 Charge of 35% will be applied to accounts sent to collections.
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 considered cash payment. An additional 3% processing fee will be charged for all card transactions.
Initial:*
For your convenience, we accept Visa, MasterCard, Discover, American Express, cash, or checkA) $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 to do so will result in a $25 late cancellation/rescheduling fee.
Initial: *
Patient or Guardian Signature*

Clear
Date

MonthDayYear
Should be Empty:

CENTRAL WASHINGTON

PATIENT INFORMATION

REFERRAL INFORMATION

GUARDIAN INFORMATION

INSURANCE AND PAYMENT INFORMATION

Healthy History:

Women Only:

Financial Statement: