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Advanced Oral Surgery & Dental Implant Studio

Address:
Grand Rapids
3855 Burton Street SE, Suite B
Grand Rapids, MI 49546

Phone:
(616) 369-0360

Hours:
Mon–Wed: 7:30 AM–5:00 PM
Thu, Fri: 7:30 AM–2:00 PM

Contact Us

Document Signers
    • 1 Patient

Page 1 of 5

Patient Information

Salutation

Gender

Have you ever been a patient of our practice

Has a family member ever been a patient of our practice


Page 2 of 5

Responsible Party

Person Responsible For Account


Insurance Information

Primary Dental


Secondary Dental

Primary Medical

Secondary Medical

I authorize my surgeon and his/her designated staff to perform an oral and maxillofacial of diagnosis and treatment planning. Furthermore, I authorize the taking of all radiographs required as a necessary part of this examination. In addition, I authorize the release of any information acquired in the course of my examination and treatment to my doctors and/or insurance carriers.


Page 3 of 5

Patient Medical History

Under Physician Care

Changes To Health

Had Anesthesia or Sedatives

Family History of Anesthesia Reactions

Family History of Heart Disease Pre 40

TMJ Problems

Accident-Related Visit

If yes, what type of accident

Have you had or do you currently have any of the following:

Angina (Chest Pain)

Heart Attack

Heart Valves/Implants/Grafts/Stents

Other Heart Surgery

Stroke

Seizures/Epilepsy

Cancer

Radiation

Chemotherapy

Diabetes

Joint Replacement Surgery

Biphosphonate Use


Page 4 of 5

Medical History (cont.)

Have you had or do you currently have any of the following:

Heart Disease

Irregular Hearbeat/Heart Murmur

Pacemaker/ICD

Congestive Heart Failure

Congenital Heart Defects

Fainting Spells

Bleeding or Clotting Disorder

Palpitations

High Blood Pressure

Low Blood Pressure

High Cholesterol

Rheumatic Fever

Breathing Problem

Dementia/Alzheimer's

Shortness of Breath

Thyroid Disease

Lung Disease

Glaucoma

Special Healthcare Needs

Asthma

Sinus Trouble

Sleep Apnea/CPAP Use

Kidney Disease

Dialysis

Stomach Ulcers

Gastroc Reflux/GERD

Liver Disease/Cirrhosis/Hepatitis

Anemia

Blood Clots, DVT, or PE

Mental Health Concerns

Sexually Transmitted Infections

Blood Thinners

HIV/AIDS

Tobacco Use

Alcohol Use

Alcohol or Drug Addiction Treatment

Recreational Drug Use


Women Only

Is there any Chance you could be pregnant

Breastfeeding

Birth Control Pills


If you are having surgery today

Need Private Counsel

If you are having IV sedation or general anesthesia today, have you had anything to eat or drink in the last 8 (eight) hours

I certify that I have read and I understand the questions above. I acknowledge that my questions, if any, about the inquiries set forth above have been answered to my satisfaction. I will not hold my doctor, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.


THE HEALTH INSURANCE PORTABILITY ACCOUNTABILITY ACT OF 1996 (HIPAA)

A copy of our practice’s Notice of Privacy Practices is available upon request.

I acknowledge that I had the opportunity to read and review a copy of this office’s Notice of Privacy Practices. I understand that I may ask any questions I may have regarding this notice.


In accordance with HIPAA Guidelines, we must have your permission to call you and/or leave a message. Please indicate below all of the ways we may get in touch with you.

Is it ok to send you a SMS text?

Is it ok to send you a voicemail?

Is it ok to send you an email?

Is it ok to leave you a voicemail?

Is it ok to leave you a voicemail?

THE HEALTH INSURANCE PORTABILITY ACCOUNTABILITY ACT OF 1996 (HIPAA)

HIPAA prevents us from disclosing any information about you to anyone (other than your medical and dental providers) without your permission.

 

To whom may we release information regarding your treatment?

PATIENT CONSENT TO DISCLOSURE OF INFORMATION:

Existing Michigan Law also requires us to first obtain your written consent prior to disclosing any of your information, except for our disclosures in connection with a defense to a claim challenging our professional competence, a review entity’s functions, a claim for payment of fees, a third-party payer’s examination of our records, a court order as part of a criminal investigation, an identification of a dead body, a licensure investigation, or a child abuse/neglect investigation. From time to time, it may be necessary for us to make disclosures of your information in connection with your treatment, to obtain payment for services we rendered, or for healthcare operations. For example, we may make a referral to or consult with another dentist or other healthcare professional, provide a specimen to a laboratory for testing, or otherwise make disclosures of your information in connection with providing or coordinating your treatment.

Patient: I consent to your disclosures of my information that you deem necessary in connection with my treatment at your office, treatment of me by another physician or healthcare provider, to obtain payment for services you rendered, or healthcare operations. I understand that such disclosures may not be of the type listed above.

FINANCIAL POLICY

 

FINANCIAL POLICY

Payment is due in full on the date of service. We accept cash, checks, Visa®, Mastercard®, Discover®, American Express®, and alternative financing through CareCredit® and Greensky®.

TREATMENT PLANS:

Treatment plans are estimates only. Actual fees can change if the actual surgery performed changes. Fees given are not guaranteed after six months.

PATIENTS WITH INSURANCE:

We collect the amount in full on the day of your appointment (consult/imaging/surgery). As a courtesy, we will submit insurance claims for you. Providing our office with accurate medical and dental insurance information will help us expedite your insurance reimbursement. This payment will go to you directly. Please remember you are responsible for all fees charged by this office regardless of your insurance coverage. Please contact your insurance company for specific details about coverage and reimbursement.

FINANCE FEE:

After 90 days, any balance unpaid by you is considered past due and is due in full. A finance fee of 1.5% is added monthly to your past due account. This represents an annual percentage rate of 18%.

RETURNED CHECKS:

To cover the office costs involved, a $25.00 fee will be added to your account balance for checks returned for any reason.

AUTHORIZATION TO RELEASE INFORMATION:

Advanced Oral Surgery & Dental Implant Studio may release information acquired in the course of examination and/or treatment for insurance claims processing and/or legal purposes as required by law.

MINORS:

If the patient is age 17 or younger, they are a minor. A parent or guardian must accompany the patient for treatment. We realize that many families are in a state of change; divorced, separated, single-parent, and blended families are now common. In many of these families, the question of who is responsible for the children’s account is uncertain. The policy in our office is that the parent who requests treatment for the child is responsible for all fees incurred. Settlement must be resolved between the parents.

PATIENTS WITH GUARDIANS:

A patient who cannot consent to treatment has a legal guardian. Our office will need a complete health history prior to the day of any treatment. A guardian must be available to discuss patient care and treatment with the doctor.

It is our privilege to serve your oral surgery care needs. If you have any questions about our financial policy after reviewing it, please contact our business office. Thank you for trusting us with your care.

AGREEMENT TO PAY:

I request and authorize Advanced Oral Surgery & Dental Implant Studio to provide me with medical or dental services. I understand that I am personally responsible for the charges incurred for the services I receive. I agree to make full payment for services I receive unless prior arrangements have been made in writing.

I agree to pay all reasonable attorney fees and costs of collection incurred by AOS if my account is not paid as agreed. I also agree to pay interest on my unpaid balance at the rate of 18% per annum, commencing 90 days after the date of service. I hereby authorize AOS, at its discretion, to bill my insurance carrier and any other persons or parties who may be liable for payment of these services.