103 Burnett Court
Waco, TX 76712
Mon–Thu: 8:00 AM–5:00 PM
Fri: 8:00 AM–3:00 PM
*Health problems or medication can have an important interrelationship with the care you will be receiving. Thank you for answering the following questions. Your answers are for our records only and will be considered confidential.
Are you allergic or have you had a bad reaction to any of the following?
Are you taking or have you taken any of the following?
Is there any condition concerning your health that the doctor should know about?
Are you in good health?
Has there been any change in your health in the past year?
Are you now under the care of a physician?
Have you had any serious illnesses, operations, or hospitalizations in the past five years?
Do you have unhealed/recurrent injuries, inflamed areas, growths, or sore spots in oraround your mouth?
Do you have a prosthetic joint/implant?
Have you had a heart valve replacement or vascular graft?
Do you wear contact lenses?
Do you wear a removable dental appliance?
Are you on a diet?
Have you had or do you currently have:
MEDICAL HISTORY UPDATED
NOTICE AND ACKNOWLEDGMENT OF RISK FORM
Our goal is to provide a safe environment for our patients and staff and to advance the safety of our local community.
This document provides information that we ask you to acknowledge and understand regarding the COVID‐19 virus.
The COVID‐19 virus is a serious and highly contagious disease. The World Health Organization has classified it as a pandemic. You could contract COVID‐19 from a variety of sources. Our practice wants to ensure you are aware of the additional risks of contracting COVID‐19 associated with dental care.
The COVID‐19 virus has a long incubation period. You or your healthcare providers may have the virus and not show symptoms and yet still be highly contagious. Determining who is infected by COVID‐19 is challenging and complicated due to limited availability for virus testing.
Due to the frequency and timing of visits by other dental patients, the characteristics of the virus, and the characteristics of dental procedures, there is an elevated risk of you contracting the virus simply by being in a dental office. Dental procedures create water spray, which is one way the disease is spread. The ultra‐fine nature of the water spray can linger in the air for a long time, allowing for transmission of the COVID‐19 virus to those nearby.
You cannot wear a protective mask over your mouth to prevent infection during treatment, as your health care providers need access to your mouth to render care. This leaves you vulnerable to COVID‐19 transmission while receiving dental treatment.
Pursuant to statements from the Centers for Disease Control (CDC) and the American Dental Association (ADA), nonessential or elective treatment, based on the assessment of our staff, will be rescheduled.
According to the ADA, dental emergencies are “potentially life threatening and require immediate treatment to stop ongoing tissue bleeding [or to] alleviate severe pain or infection.” The ADA also recommends that urgent dental care which “focuses on the management of conditions that require immediate attention to relieve severe pain and/or risk of infection and to alleviate the burden on hospital emergency departments” be provided in as minimally invasive a manner as possible.
I confirm that I have read the Notice above and understand and accept that there is an increased risk of contracting the COVID‐19 virus in the dental office or with dental treatment. I further confirm I am seeking treatment for a condition that meets the emergent or urgent criteria noted above. I understand and accept the additional risk of contracting COVID‐19 from contact at this office. I also acknowledge that I could contract the COVID‐19 virus from outside this office and unrelated to my visit here.
I have read and understand the information stated above:
I certify that I have read and understand the questions regarding my health history, submitted today via computer and saved in my electronic medical record. I acknowledge that any questions about these inquiries have been answered to my satisfaction. I will not hold my surgeon or any other member of his staff responsible for any errors or omissions that I have made in the completion of this form.
FEES AND PAYMENTS
We make every effort to keep down the cost of your oral surgical care. You can help by making payment at the conclusion of your consultation and prior to your surgical procedure. An estimate of the cost of your procedure will be provided for you. If you have any dental and/or medical insurance, we will be glad to fill out the proper forms, but please be certain the information provided is complete and accurate.
Also 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 a fixed allowance for certain procedures while others pay a percentage of total costs. It is your responsibility to pay any deductible amount, co-insurance or any balance not paid by your insurance company.
Recent changes and restrictions require we get approval to contact him/her via cell phone. Your signature below verifies that cell phone contact is allowed.
I authorize my surgeon and his 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.
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.
By signing below, I acknowledge that I’ve read and understand the policies found above.