512 N Young Street
Kennewick, WA 99336
Mon–Fri: 7:00 AM–5:00 PM
Thank you for selecting our surgical team! We strive to provide you with the best possible care. To help us meet all your surgical healthcare needs, please fill out this form completely. If you need any assistance or have any questions, please ask our friendly staff - we will be happy to help.
Are you in good health?
Has there been any change in your general health in the past year?
Are you under a physician's care, or have you been in the past five years, including hospitalizations and surgeries?
Have you taken Cortisone or other steroids in the past 24 months?
Have you had ophthalmic (eye) surgery in the past 8 weeks?
Have you or your family had a reaction to dental or general anesthetic?
Have you had any adverse effects from dental treatment?
When you walk up stairs or take a walk, do you ever have to stop because of pain in your chest, shortness of breath, or because you feel very tired?
Do you take or have you taken:
Do you wish to talk with the doctor about anything privately?
Payment Plan Options
We are not contracted with most insurance companies. Your insurance coverage is a contract between you and your insurance company. If we have the necessary information, we will be glad to assist you in the submission of your claim, but payment of your account is ultimately your responsibility. Any fees left unpaid by your insurance are payable by you in full upon receipt of negotiating a disputed claim. You are responsible for payment of the balance of your account regardless of payment from insurance after 60 days from your initial date of treatment. Insurance coverage is not a guarantee of payment! Insurance plans vary widely in their policy provisions and benefit amounts; therefore, the amount quoted as your co-payment should not be relied upon to be your total balance due. We can only estimate your coverage and co-payment, so your understanding of your policy is your best assurance that your claim will be properly administered.
I authorize my insurance company to release benefits to my doctor that would otherwise be paid to me. I also authorize the doctor to release any information required for the administration of my claims.
I have read and I understand the terms of payment as outlined above. I agree that in the event I default and not make payment in accordance with the terms indicated above, my account will be transferred to a collection agency and that I will be responsible for the costs of collection including reasonable attorney’s fees in an amount that can be 33% of the principal amount sued upon. I understand that there is a minimum $30 service charge for any NSF check returns and that future payments will be cash only.
Are you currently enrolled in any Medicare or Medicare Advantage Plan?
The above information is accurate and complete to the best of my knowledge and is only for use in my treatment, billing, and processing of insurance for benefits for which I am entitled. I will not hold Dr. Cooper, Dr. Teeples, Dr. Toponce, Dr. Reddinger, or any members of their staff responsible for any errors or omissions that I may have made in the completion of this form.
To the best of my knowledge, all of the preceding answers are true and correct. If I ever have any change in my health, abnormal laboratory tests, or if my medicines change, I will inform the doctor at the next appointment without fail. I have had a chance to ask questions. I understand x-rays and local anesthetics may be required for treatment. I also state I read and write in English, or this information has been translated to me in my primary language.
Are you having your wisdom teeth removed?
Would you like to learn more about Stemodontics® and the benefits of banking stem cells from wisdom teeth?