Patient Information Package

Your medical history is important to the treatment you will receiv. Therefore, it is important that you respond to each question honestly and completely.

Do you have or have you ever had:

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

Female Patients

Are you using any of the following?

Are you using any of the following?

Have you ever sought professional care or been hospitalized for:

Do you use:

In general, the HIPAA privacy rule gives individuals the right to request a restriction on uses and disclosures of their protected health information (PHI). The individual is also provided the right to request confidential communications or that a communication of PHI be made by alternative means, such as sending correspondence to the individual's office instead of the individual's home.

If you wish to obtain a copy of our privacy practices, please inform the staff upon returning this form.

I have received a copy of Northeast Arkansas Center for Oral and Maxillofacial Surgery, Notice of Privacy Practices which describes how my health information is used and shared. I understand that Northeast Arkansas Center for Oral and Maxillofacial Surgery, has the right to change this notice at any time. I may obtain a current copy by contacting the Facility Privacy Officer, or by visiting the Facility website at www.neaoralsurgery.com.

In the event of a medical emergency, NEA Center for Oral and Maxillofacial Surgery does not accept advance directives for non-resuscitation. Advanced directives will be included with transfer to a higher level of care if provided.

Questions concerning this policy can be directed to the clinic manager; Medicare.gov or Arkansas Code Title 20-6-103.

My signature below acknowledges a copy was offered/received. (Not necessarily read).

Dear Patient:

When we make your appointment, we are reserving a time slot for you with the doctor. We ask that if you must change an appointment, please give us at least 24 hours notice. This courtesy makes it possible for us for us to give your reserved slot to another patient.

We make every effort to be on time for all our appointments. Unfortunately, when even one patient arrives late, it can throw off the entire schedule for that session. In addition, rushing or "squeezing in" an appointment shortchanges the patient and contributes to decreased quality of care (and increases medical errors). In light of this, patients arriving more than 5 minutes after their appointment time will be asked to reschedule. We apologize for any inconvenience this might cause.

Repeated cancellations or missed appointments will result in loss of all future appointment privileges.

By implementing this policy, we believe we honor patients who schedule/keep appointments, while also trying to accommodate everyone inn a fair and efficient manner. Thank you for your cooperation.