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Patient packet-swoms

Southwest Oral & Maxillofacial Surgery
Kurt F. Martin, DDS, MD
Ronald L. Roholt, DDS, MD
Craig E. Miller, DDS
311 Campus Drive, Ste 101
Dear Patient, We welcome you to our practice and are happy to have the opportunity to serve you. We take pride in our efforts to make your visit to our office a pleasant experience. Your oral health and comfort are our primary concerns. If you are unable to keep your appointment, please contact our office as soon as possible to let us know. If you are under the age of 18 a parent or guardian must accompany you. Please find the attached Patient Information Sheet and Medical History forms. We ask that you do the following prior to your appointment: • Please complete the forms in their entirety and sign where necessary. • We will take a photocopy (front and back) of your insurance card(s) when you come in for your appointment. We need both medical and dental insurance information. We do not accept Medicaid. • Please bring your personal calendar with you for scheduling your next There is a map enclosed to assist you in your visit to our office. If you have any questions, please do not hesitate to call us at the above number. Office hours are Tuesday through Thursday 8:00-5:00, Friday 8:00-4:30, closed on Mondays and from 12:00-1:00. Sincerely, Southwest Oral & Maxillofacial Surgery Enclosures WELCOME TO OUR OFFICE
Today’s Date_______________________________________ Your first visit is consultation only. Surgery will be scheduled for a later date.
Thank you for choosing our office. We will strive to provide you with the best possible care. To help us meet all
your healthcare needs, please fill out this form completely in ink. If you have any questions or need assistance,
please ask us—we will be happy to help you. All information will be kept confidential. Please print.
Full Name _______________________Age_______Birthdate__________________Soc. Sec.#_________________
MailingAddress_____________________________City_______________________State________Zip___________
Employed by_______________________Home Ph. #___________________Work/Cell Ph.____________________
Please circle appropriately:

Minor Single Married Divorced Widowed Separated
Spouse’s Name _________________________________________________

Have you or any family members been a patient here before? Name_______________________Year:__________
Answer only if you are a dependent:
Mother’s Name _______________________________ Father’s Name_____________________________________
Parent’s Address ______________________________City_____________________State_______ Zip___________
Parent’s Home Ph.#__________________________ Parent’s Work Ph.#__________________________________
Places of employment_____________________________________________________________________________
PERSON FINANCIALLY RESPONSIBLE FOR THIS PATIENT?
Name______________________Signature of person financially responsible______________________________________
Address _________________________________________City______________________State________Zip____________
Home Ph.#____________________Work Ph. #____________________Employer____________________________
Relationship to this patient?__________________________SS #___________________DOB__________________
INSURANCE INFORMATION

Subscriber’s Name _______________________________________________

Subscriber’s Social Security #_____________________________Subscriber’s date of birth ___________________
Do you have Dental Insurance? O Yes O No

Name of Company_______________________________

Do you have Medical Insurance? O Yes O No

Name of Company ______________________________

Physician’s Name__________________________General Dentist’s Name_________________________________
Reason for today’s visit?__________________________________________________________________________
Who may we thank for referring you to our office?____________________________________________________
AUTHORIZATION AND RELEASE
I certify that I have read and understand the above information to the best of my knowledge. The above questions have been
accurately and completely answered. I hereby grant permission to the doctor and staff of this office to release information including
the diagnosis and the records of any treatment or examination rendered to me to assist in obtaining payment from my insurance
carriers. I authorize and request my insurance company to pay directly to the doctors of this practice. I understand that my insurance
carrier may pay less than the actual bill for services. I AGREE TO BE RESPONSIBLE FOR PAYMENT OF ALL SERVICES
RENDERED ON MY BEHALF OR TO MY DEPENDENTS AT TIME OF SERVICE. I grant permission to the doctors or staff of
this office to release medical information to my dentist or other medical personnel as deemed necessary in treating my current
condition.
Patient, parent or guardian signature ___________________________________________________________________

Southwest Oral & Maxillofacial Surgery Medical History

Patient Name: ___________________________ Date of Birth :______________ Today’s Date: _____________
Current Medical Conditions

Have you had:
Describe
___ __________________________________________________ Anesthesia complications (including local) ___ ___________________________________________________ Unfavorable reaction to dental treatment ___ ___________________________________________________ Do you have or have you had problems with the following?
Eyes (cataracts, glaucoma, contacts, etc.)
___ ___________________________________________________ ___ ___________________________________________________ ___ ___________________________________________________ Heart (chest pain, irregular beat, MI, murmur) ___ ___ ___________________________________________________ ___ ___________________________________________________ ___ ___________________________________________________ ___ ___________________________________________________ Blood (bleeding, clotting, transfusion, bruising) ___ ___ ___________________________________________________ ___ ___________________________________________________ ___ ___________________________________________________ ___ ___________________________________________________ ___ ___________________________________________________ ___ ___________________________________________________ Brain (Stroke, TIA, Alzheimer’s, seizures) ___ ___________________________________________________ ___ ___________________________________________________ ___ ___________________________________________________ ___ ___________________________________________________ ___ ___________________________________________________ ___ ___________________________________________________ ___ ___________________________________________________ Etidronate (Didronel); Tiluderonate (Skelid); Alendronate, (Fosamax); Risedronate (Actonel); Ibandronate (Boniva),Pamidronate, (Aredia); Zoledronate (Zometa); or (Reclast) Females: Might you be pregnant?
___ ______________________________________________
Family History

Have any occurred in your family?
Describe
___ __________________________________________________ ___ __________________________________________________ ___ __________________________________________________
Social History

Have you had any of the following?
Describe
___ __________________________________________________ ___ __________________________________________________ ___ __________________________________________________ ___ __________________________________________________ Have you had:
Describe
_____________________________________________ _____________________________________________
Medications
(Include all non-prescription meds, aspirin, vitamins, and herbals)
Name of Medication
_________ ____________________________________________________________ _________ ____________________________________________________________ _________ ____________________________________________________________ _________ ____________________________________________________________
_____________________
_________ ____________________________________________________________ _________ ____________________________________________________________ _________ ____________________________________________________________ _________ ____________________________________________________________ _________ ____________________________________________________________ Have you taken aspirin containing products in the last two weeks? Have you taken steroid or cortisone-type drugs within the last two years?

Allergies
(Include medications, environmental agents, foods, latex, tape, etc.)
Name

_____________________ ________________________________________________________________________
_____________________ ________________________________________________________________________
_____________________ ________________________________________________________________________
_____________________ ________________________________________________________________________
Person Completing This Health History

Name: __________________________________ Date: ________________________
I certify that I have understood all items and have answered the questions accurately and completely.
Signature: _____________________________________ Date: ___________________
THIS PAGE TO BE COMPLETED BY MEDICAL TEAM ONLY

Vital Signs: For Medical Team Use Only

Blood Pressure: _______/_______ Pulse: ___________ Respirations: ___________ Temperature: ___________

Height: ___________
Weight: _________ O Saturation: __________
Doctor Reviewing This Form
Signature: _____________________________________ Date: ___________________ Signature: _____________________________________ Date: ___________________ Signature: _____________________________________ Date: ___________________
MEDICAL UPDATE: I have reviewed my health history dated ______________________ and confirm that it
accurately states past and present conditions.
EXCEPTIONS:
Signature of Person completing Health Update
Doctor Reviewing This Form
Signature: _____________________________________ Date: ___________________ Signature: _____________________________________ Date: ___________________ Signature: _____________________________________ Date: ___________________ Southwest Oral & Maxillofacial Surgery
FINANCIAL POLICY
Thank you for choosing Canterbury Oral & Maxillofacial Surgery as your oral surgery provider. We are committed to your treatment being successful. The following is a statement of our Financial Policy. WE ACCEPT CASH, CHECKS, ALL MAJOR CREDIT CARDS, or payment plans through Care Credit to meet your financial obligations at the time services are received. Regarding Insurance.
We will accept assignment of insurance benefits. If we are a participating provider for your insurance
company, your estimated deductible and co-insurance amounts are due at the time of treatment. Any
balance due after your insurance company has paid their portion or denied payment is your
responsibility
. Your insurance policy is a contract between you and your insurance company. We cannot
bill your insurance company unless you give us current and correct information which includes a copy of
the current insurance identification card, social security number, full and legal name, birth-date of the
insured, and current address. Please be aware that some, and perhaps all, of the services provided may be
non-covered services.
If you do not have insurance, full payment is due the day of service. We do not accept Medicaid.
Usual and Customary Rates.
Our practice is committed to providing the best treatment for our patients and we charge what is usual and
customary for our area. Please understand that some insurance companies arbitrarily determine usual and
customary fees based on their own interest.

Responsible Party.
The responsible party is obligated for full payment at the time of service.

Miscellaneous fees.

Past due accounts may be subject to collection fees and/or third party action.
If there are extenuating financial circumstances, please communicate this to our staff. We must collect fees
so that we can meet our financial obligations and continue to serve the people of Western Kansas. Thank
you for understanding.

I understand and agree to the Financial Policy:

___________________________________________Date______________________________________
Signature of Patient or Responsible Party

Source: http://www.southwestoms.net/yahoo_site_admin/assets/docs/Patient_Packet-SWOMS.146130943.pdf

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