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Balaci Oral and Facial Surgery

Address:
Lebanon
860 Tuck St.
Lebanon, PA 17042

Phone:
(717) 273-6745

Hours:
Mon - Thu: 8:00 AM–5:00 PM
Fri: 8:00 AM–2:00 PM

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Page 1 of 5

General Patient Information

Title

Gender

Have you ever been a patient of our practice?

Has a family member ever been a patient of our practice?

Payment Type


Page 2 of 5

PERSON RESPONSIBLE FOR ACCOUNT

If self, skip this section

SPOUSE OR OTHER GUARANTOR INFORMATION

If self, skip this section


Page 3 of 5

INSURANCE INFORMATION

Student

Marital Status

Employed

Do you belong to a PPO or HMO?

Primary Dental Insurance Company

Gender

Secondary Dental Insurance Company

Gender

Primary Medical Insurance Company

Gender

Secondary Medical Insurance Company

Gender


Page 4 of 5

Health History

To our patients: Although oral surgeons primarily treat the area in and around your mouth, your mouth is part of your entire body. Health problems that you may have or medications that you may be taking could have an important interrelationship with the care that you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.

ALLERGIES

Are you allergic to or have you had a reaction to:

MEDICATIONS

Are you now taking

Are you in good health?

Have there been any changes in your general health in the past year?

Are you under the care of a physician?

Have you had an illness, operation, or been hospitalized in the past 5 years?

Do you have unhealed/recurrent injuries, inflamed areas, growths, or sore spots in or around your mouth?

Do you have a prosthetic joint/implants?

Have you had a heart valve replacement or vascular graft?

Have you ever had general anesthesia?

Have you or a family member had any unusual or serious reactions to general anesthesia?

Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?

Are you currently on a diet?

Do you wear contact lenses?

Do you have or have you had a removable dental appliance?

Have you had or do you currently have


Page 5 of 5

Health History Continued

If you are having surgery today, have you had anything to eat or drink in the last 6 (six) hours?

Is there any condition concerning your health that the doctor should be told about?

Do you wish to speak to the doctor privately about anything?

INSURANCE CLAIM INFORMATION

WOMEN ONLY

Is there a possibility of pregnancy?

Are you nursing?

Are you taking birth control pills?

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.

FEES & PAYMENTS: 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 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 by your insurance company. You will be responsible for all collection costs, attorney’s fees, and court costs.

This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment to this doctor named of the benefits otherwise payable to me.

AUTHORIZATION: I authorize my surgeon 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 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.