Signature Oral Surgery – New Patient Intake Form
Demographic Information Please do not input special characters into your name, including hyphens.
May we send text messages to this phone?
May we send text messages to this phone?
Were you referred to our practice by your dentist?
If no, how did you hear about us?
Have you ever been a patient of our practice?
Does the patient have a legal guardian?
Does the patient require an interpreter?
Who will be responsible for your account?
Who will be responsible for your account?
Is this related to an accident?
Is this visit related to an accident?
If yes, indicate type of accident
Insurance Information General Insurance Information
Primary Dental Insurance Information
Primary Medical Insurance Information
Do you have secondary dental or medical insurance?
Secondary Dental Insurance Information
Secondary Medical Insurance Information
Health History Health History Questionnaire
Please indicate any health issues that apply for the patient
Patient has been hospitalized in the past year?
Patient has a prosthetic joint or heart valve replacement?
Patient or a family member has had an unusual or serious reaction to general anesthesia?
Patient under the care of a pain management or addiction specialist?
Health History Part 2 If any of the following categories is YES, please indicate the condition.
If yes, please indicate the condition
If yes, please indicate the condition
If yes, please indicate the condition
If yes, please indicate the condition
If yes, please indicate the condition
If yes, please indicate the condition
If yes, please indicate the condition
If yes, please indicate the condition
If yes, please indicate the condition
If yes, please indicate the condition
If yes, please indicate the condition
If yes, please indicate the condition
History of Head and / or Neck Radiation
History of Head and / or Neck Radiation
If yes, please indicate the condition
If yes, please indicate the condition
Smoke, Vape or Tobacco Use
Smoke, Vape or Tobacco Use
If yes, please indicate type
Dependency, Mis-Use or Abuse — Current or History
Dependency, Mis-Use or Abuse — Current or History
If yes, please indicate the condition
Are you currently in a care program for this history?
Are you under a contract with your treating provider?
Pain Management Program or Recovery Program
Pain Management Program or Recovery Program
Are you or could you be pregnant?
Other Medical Condition Not Addressed
Other Medical Condition Not Addressed
Patient / Guardian Signature
Medications / Allergies Please list any medications you are currently taking
Additional medications (name, dosage, frequency — one per line)
Are you allergic to, or have you had a reaction to:
Codeine or other narcotics
Please list any other medication or antibiotic you are allergic to or have been advised not to take
List any surgeries, operations, or procedures you have undergone and when
Surgeries / operations / procedures and dates
Medical Health History Acknowledgement We make every effort to keep down the cost of your care. You can help by paying upon completion of each visit. Other arrangements can be made with our office manager depending upon special circumstances. An estimate of the charge for any procedure or surgery you may require will be given to you upon request. If you have any dental and/or medical insurance we will be glad to fill out the proper forms, but please complete the identifying information on this form.
Please remember that insurance is considered a method of reimbursing the patient for fees paid to the doctor and is not a substitute for payment. Some companies pay fixed allowances for certain procedures and others pay a percentage of the charge. It is your responsibility to pay any deductible amount, co-insurance or any other balance not paid for by your insurance company. You will be responsible for all collection costs, attorneys’ fees, and court costs.
Signature Oral Surgery is only a part of a coordinated care team that may be required for all of my or the patient’s needs. I understand that I would also be responsible for payment for services provided by the general dentist, other dental practitioners, laboratories and pathology services (e.g. review of biopsy specimens), and/or hospitals, clinics and medical providers at other facilities, where I may need follow-up evaluation and additional treatment related to my care at Signature Oral Surgery or any complications I may encounter.
The signature below is my authorization for the release of information necessary to process my claim. I hereby authorize payment to the provider named or the benefits otherwise payable to me. Also, my signature below confirms I understand and agree with the FEES & PAYMENT POLICY as noted above.
I authorize Signature Oral Surgery, my provider and his / her designated staff, to perform an oral and maxillofacial examination, for the purpose of diagnosis and treatment planning. Furthermore, I authorize the taking of all x-rays required as a necessary part of this examination. In addition, if medically necessary, I authorize the release of any information acquired in the course of my examination and treatment to my other doctors and/or insurance carriers. I permit messages to be left on my phone and / or mobile phone concerning my appointment. My signature below confirms I understand and agree with the AUTHORIZATION POLICY for evaluation and treatment noted above.
Consent for Photography / Radiographs
I hereby acknowledge that during the course of my treatment, photographic records and additional radiographic imaging may be taken. These images will be retained as a part of my clinical record. My identity and images will be protected as per corporate policy towards all clinical records. I understand that these images may be used for: research purposes, relevant scientific and dental literature publications, professional website, dental and oral surgical conferences and meeting presentations and for educational purposes with other dental professionals and education of other potential patients that come to our offices. The images may be modified in ethical practices such as realigning, rotating, cropping and color correction such as exposure and contrast.
Cancellation, No Show and Missed Appointments
With the nature of an outpatient surgical office and allocation of time needed for completion of surgical services: missed appointments, “no shows” and last minute cancellations are disruptive to the practice and other patients. You are being advised that you (or the patient) may be dismissed from the practice and unable to make additional appointments if you (or the patient) fail to attend scheduled appointments without notifying the office at least one business day in advance.
I understand that failure to attend scheduled appointments without one business day notice may allow for dismissal from the practice and inability to schedule any future appointments.
Privacy and Personal Representative Authorization for Information Release Policy
I hereby acknowledge that a copy of this office’s Notice of Privacy Practices has been made available to me. I have been given the opportunity to ask any questions I may have regarding this Notice. I understand that a copy of the Privacy Practices is available for me. My signature below confirms I understand and agree with the PRIVACY and PERSONAL REPRESENTATIVE AUTHORIZATION FOR INFORMATION RELEASE POLICY as noted above.
Personal Representative Authorization for Information Release Please list below anyone that you will allow us to discuss this account with and their relationship to you.
Signature of Patient (Parent or Guardian if Minor)
Submit Intake Form
