122 La Casa Via, Ste 223
Walnut Creek, CA 94598
Mon, Tues, Thur: 8:00 AM–5:00 PM
Wed: 8:00 AM–12:00 PM
Fri: 8:00 AM–1:00 PM
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Have you ever been a patient of our practice?
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Who Will Be Responsible For Your Account? (if Self, skip to the next section)
Do you belong to a PPO or HMO?
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To our patients: Oral surgeons primarily treat the area in and around your face and mouth. These are part of your entire body, and health problems that you may have or medication 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.
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 any illness, operation, or been hospitalized in the past 5 years?
Do you have unhealed injuries or inflamed areas, growths, or sore spots in or around your mouth?
Do you have a prosthetic joint/implant?
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Have you had a heart valve replacement or vascular graft?
Do you have a history of TMJ (jaw joint) problems?
Damaged heart valves/mitralvalve prolapse?
High blood pressure?
Chest pain, angina?
Irregular heart beat?
Bronchitis, chronic cough?
Hay fever/sinus problems?
Difficult breathing/other lung trouble?
Do you smoke?
Blood disorder, such as anemia?
Bleeding tendency (abnormal bleed)?
Jaundice, hepatitis, or liver disease?
Low blood sugar?
Low Blood Pressure?
Are you on dialysis?
Swollen ankles, arthritis or joint disease?
Sexually transmitted diseases?
Problems with the immune system?
Delay in healing?
A tumor or growth?
Chronic fatigue/night sweats?
Are you on a diet?
A history of drug abuse?
A history of alcohol abuse?
Mental health problems?
A removable dental appliance?
Pain and clicking of jaws when eating?
Have you had, or do you currently have any, of the items above?
IF YOU ARE HAVING SURGERY TODAY, have you had anything to eat or drink in the last 6 hours?
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Any kind of medicine, drugs, or pills?
Blood thinners (e.g., Coumadin®, Plavix®, aspirin, or Advil®)?
Diet pills (now or in the past)?
Bisphosphonate medications (now or in the past) (e.g., Fosamax®, Zomeda®, Actonel®)?
Any kind of natural product, herbal supplement, or homeopathic remedy?
Please list all medications you are currently taking:
Sodium Pentothal, propofol, Valium®, or other tranquilizers?
Codeine or other narcotics?
Sulfites, soy products, or eggs?
WOMEN NOTE: Antibiotics (such as penicillin) may alter the effectiveness of birth control pills. Consult your physician/gynecologist for assistance regarding additional methods of birth control.
Is there a possibility of pregnancy?
Are you nursing?
Are you taking birth control pills?
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?
Is there a family history of (check if applies):
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 surgeon, or any other member of his/her staff, responsible for any errors or omissions that I have made in the completion of this form.
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We make every effort to keep down the cost of your oral surgical 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 fee 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 is 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 for 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.
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.
I acknowledge that I have received a copy of the Notice of Privacy Practices for the offices of Muir Oral, Facial, & Dental Implant Surgery. The Notice of Privacy Practices describes the types of uses and disclosures of my protected health information that might occur in my treatment, payment for services, or in the performance of office health care operations. The Notice of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Notice of Privacy Practices is also posted in the facility. Muir Oral, Facial, & Dental Implant Surgery reserves the right to change the privacy practices currently described in the Notice of Privacy Practices. If Privacy Practices change, I will be offered a copy of the revised Notice of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a Notice of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.
ADDITIONAL DISCLOSURE AUTHORIZATION
In addition to the allowance disclosures described in the Notice of Privacy Practices, I hereby specifically authorize disclosure of my Protected Healthcare Information to the person(s) identified below. (I understand that the default answer is “NO.” Without indicating “YES” in answer to each individual question, personal protected health information (PHI) cannot be shared with anyone unless otherwise allowed by HIPAA rules.)
Any member of my immediate family (spouse, children, children's spouses)
Any member of my extended family (parents, grandchildren)