Belleair Oral Surgery & Implants

| | ^ ^ Ralph M . Eichstaedt, DDS

Patient's Information

First Name: Last Name:.

Date of Birth: Social Security #:

Marital Status: • Single

Mailing Address:

• Married

Sex: • Male • Female

• Divorced • Widowed • Separated

City, State, Zip:

DL # (of responsible party):

Home Phone:

Employer: ^

Work Phone: Mobile Phone:

Address:

Emergency Contact: Phone #: Relation:

How were you referred to our office? • Dentist • Medical Doctor • Insurance Company • Other

Name:

Responsible Party (Only if patient is under 18)

„. ^. Last Name: First Name: ^ Date of Birth:

Social Security #:. Relationship to patient:

Marital Status: • Single • Married Q Divorced • Widowed • Separated

City, State, Zip:

Sex: • Male • Female

Mailing Address:

Home Phone:

Employer:

Work Phone: Mobile Phone:

Address:

If Accident Related

Due to injury? • Yes • No I f yes, injury date:

• On the job

Insurance Name:

• Auto accident • Other:

Phone:

Company Address: City, State, Zip:

Please complete back side of form

Financial Consent

Dental

Insurance Name: Primary Secondary

Insurance Name:

ID#: Group #: ID #: Group #:

Policyholder:

Social Security #:

Date of Birth:

Medical

Insurance Name:

Policyholder:

Social Security #:

Date of Birth:

Primary Insurance Name:

Secondary

ID #: Group #: ID #: Group #:

Policyholder: Policyholder:

Social Security #: Social Security #;

Date of Birth: Date of Birth:

A NSF fee will be charged to the patient in the event that their check is returned to us for non-payment.

Patients With Insurance: At the time of surgery, patients are required to make payment toward the estimated charges, the patient is responsible for all insurance claims not paid within 90 days of service. The estimate we give you is never a guarantee that the amount given is what insurance will actually pay. Insurance will not guarantee any benefit until we actually file the claim. The patient is responsible for any additional monies owed after insurance pays. Patients With Medicare: Dental procedures are not billable expenses to Medicare. However, i f you will be having a medical procedure only, please provide us with your Medicare information and we will submit your claim. Patients Without Insurance: Payment in full is due on the day the services are provided.

I imderstand that Belleair Oral Surgery & Implants is filing my insurance claim for me. Although Belleair Oral Surgery & Implants extends this courtesy to me, I understand that obtaining payment by my insurance company is ultimately my responsibility. Preauthorization by your insurance company is not a guarantee of the quoted benefit. I also understand that I am responsible for any copayments, deductibles or billable charges due to plan limitations/exclusions and/or that are not covered and/or denied by my insurance company. Insurance companies do not guarantee benefits until the claim is received.

I certify that the information I have reported with regard to my insurance coverage is correct and I authorize the release of any information relating to any claim for benefits, in order to process any claim for benefits. Furthermore, I permit a copy of this authorization to be used in place of the original.

Signature of Patient or Responsible Party (only i f under 18) Date Relationship to Patient

BELLEAIR ORAL SURGERY & IMPLANTS

PERMISSION TO DISCUSS YOUR HEALTH INFORMATION WITH OTHER INDIVIDUALS

Patient Name: D.O.B:

May we e-mail you with your personal health information (Example: X-rays, Financials, Office notes) Yes No If yes, please provide us with you e-mail address:

May we e-mail/fax or discuss your person health information to/with other physicians participating in your care such as your general dentist, primary care physician, or a specialists (Example: X-Rays, Financials, Office notes. Test results or care received)

Yes No

Please list the names of individuals with whom are not one of your physicians that we may discuss your private health information with (Example: Treatment performed, Financials)

Name Relationship to Patient Contact Number

1.

2.

3.

4.

5.

By signing this form, I hereby grant permission to the staff of Belleair Oral Surgery & Implants to discuss information related to my care with the individuals listed above (This release includes all physicians that are an active part of my care.)

Signature: (Patients that are 18 years and older must sign this form. The signature of a parent, guardian or spouse is not acceptable.)

Relationship to patient: Date:

Please complete back side of form

BELLEAIR ORAL SURGERY & IMPLANTS

NOTICE OF PRIVACY POLICIES CONSENT

Our Notice of Privacy Policies provides information about liow we may use and disclose Protected Health Information about you. The Notice 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 contactiVig 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 restnction, but if we do, we shall honor that agreement.

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 of 1996 (HIPAA).

The patient understands that:

• Protected Health Information may be disclosed or used for treatment, payment or health care operations.

• The Practice has a Notice of Privacy Practices and that the patient has the opportunity to review this Notice.

• The Practice reserves the right to change the Notice of Privacy Policies. • The patient has thie right to restrict tfie uses of their information but the Practice does not

have to agree to those restrictions. • The patient may revoke this Consent in writing at any time and all future disclosures will then

cease. • The Practice may condition treatment upon the execution of this Consent.

Patient (or Legal Guardian's) Signature Date

Relationship to patient

Patient Medical History

Patient's Name: DOB: Age: Height: Weight:

The following medical information is for your general welfare, whether you are here for diagnostic consultation, a simple extraction, or a major oral surgical procedure. Your general health may have a significant affect on your current condition and on the outcome of any proposed treatment. For the sake of your overall health and safety, please answer all questions. Please circle Yes or No and explain where necessary.

Yes / No Are you seeing a specialist now (cardiologist/hematologist, etc.)?

Yes / No Are you under the active care of a physician for any reason?

Yes / No When was your last physical examination. Was anything unusual or abnormal found?

Yes / No Are there any other medical conditions we should be aware of?

Yes / No Are you taking diet pills at this time?

Yes / No Have you ever taken any of following diet pills?

Fen-Phen (fenfluramine & phentermine) Pondimin (fenfluramine) Redux (dexfenfluramine)

Yes / No I f you have ever taken any of the above drugs, have you had a medical examination to insure that your heart valves were not

affected?

Yes / No Do you have a cough or cold at this time?

Yes / No Do you use tobacco products? Type Usage

Yes / No Do you drink alcoholic beverages? Usage Yes / No Personal or family history of problems with anesthesia including malignant hyperthermia (MH)?

General Dentist Name: Phone Number:

Medical Doctor's Name: Phone Number:

Women Only

Yes / No Pregnant/Trying to get pregnant? Yes / No Taking oral contraceptives? Yes/No Nursing?

Do you have, or have you ever had any of the following? Please mark all that apply.

) Heart Murmur/Abnormal Heart Sound ) Irregular Heart Beat ) Rheumatic Fever/Rheumatic Heart Disease ) Heart Disease/Heart Attack ) Lung Trouble/TB/+PPD ) Shortness of Breath ) Swelling of Ankles ) Anemia/Sickle Cell Disease ) High or Low Blood Pressure ) Diabetes ) Bleeding Problems/Bleed or Bruise Easily ) Cerebrovascular Disease (Stroke/TIA) ) Prosthetic Joint Surgery (Artificial) ) Dizziness/Fainting ) Jaundice or Liver Disease/Hepatitis ) Sinus Problems ) Convulsions/Seizures/Epilepsy

( ) Kidney Disease ( ) Painful Joints ( ) Pain In Chest ( ) Pain In Arms ( ) Arthritis ( ) Asthma/Bronchitis/Pneumonia ( ) Snoring/Sleep Apnea ( ) A.C.T.H./Steroids ( ) Blood Transfusion/

Told you cannot donate blood? ( ) Ulcers ( ) Thyroid Disease ( ) Glaucoma ( ) Immune System Compromise/

Frequent Infections ( ) Tumor/Cancer/Radiation Treatment/

Chemotherapy

( ) Anxiety/Depression/ Psychiatric Illness Requiring Treatment by a Psychiatrist/ Psychologist

Have you ever had allergies to: ( ) Any Foods:

( ) Penicillin ( ) Aspirin ( ) Codeine ( ) Demerol ( ) Iodine ( ) Anesthetics (such as

Novocain, etc.) ( ) Latex

( ) Other Drugs:

Please complete back side of form

Patient's Name:

Please list current medications, including over the counter medication and supplements.

Please list all surgeries:

I understand the importance of providing a truthful health history to assist my doctor in providing the best care possible. I certify that the information provided here is accurate and complete and that I will ask questions of my doctor and assisting staff to clarify any items I do not understand.

Signature of Patient or Responsible Party (only i f under 18) Date Relationship to Patient

DOCTOR'S REVIEW

Doctor signature Date

MEDICAL HISTORY UPDATE (to be filled out at follow-up appointment)

Yes / No Has there been any changes in y our health since you last reviewed this form?

Yes / No Are you on or taking any new medications?

Doctor signature Date

Notes (office staff only):