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North Iowa Oral Surgery & Dental Implant Center

Address:
Mason City
1530 S Monroe Ave
Mason City, IA 50401

Phone:
(641) 424-1656

Hours:
Mon–Thu: 8:00 AM–5:00 PM
Fri: 8:00 AM–3:00 PM

Contact Us

Document Signers
    • 1 Signer

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Page 1 of 7

General Patient Information

Title

Gender

Have you ever been a patient of our practice?


Page 2 of 7

PERSON LEGALLY RESPONSIBLE FOR ACCOUNT (IF UNDER 18)

(If self, skip next section.)

Who will be responsible for your account?

Insurance Information

Insurance

Primary Dental Insurance

Gender

Primary Medical Insurance

Gender

Secondary Dental Insurance

Gender

Secondary Medical Insurance

Gender


Page 3 of 7

Health History

For the following questions, check yes or no, whichever applies. Your answers are for our records only and will be considered confidential.

Are you under the care of a physician?

Are you taking any medicine(s) including non-prescription, homeopathic, natural remedies, ordiet pills?

Do you take or have you ever taken or been given any of the following medications? (Check those that apply.)

Are you allergic to or have you had a reaction to any of the following?

Local Anesthetics

Penicillin or antibiotics

Barbiturates or sleeping pills

Aspirin or ibuprofen

Iodine

Codeine or other narcotics

Latex or rubber products

Other

Have you had any surgery, serious illness, or hospitalization in the past?

Have you or any family members had any serious reactions to IV sedation or general anesthesia?

Do you have or have you had any of the following diseases or problems?

Damaged Heart Valves, Artificial Valves, or Heart Murmur

History of Snoring, Sleep Apnea, or Use of CPAP

Rheumatic Heart Disease

Heart Attack, Heart Surgery, or Irregular Heartbeat

High Blood Pressure


Page 4 of 7

Health History Continued

Respiratory problems?

Asthma, Hay Fever, or Allergies

Emphysema, Bronchitis, Etc.

Sinus Trouble

Tuberculosis

Stomach Ulcer or Frequent Heartburn

Liver Trouble (Hepatitis, Jaundice, or Liver Disease)

Kidney Trouble

Diabetes

Thyroid Problems

Arthritis or Painful, Swollen Joints Including Jaw Joint (TMJ)

Seizures (Epilepsy), Stroke, or Neurological Disorder

Any disease, drug, or transplant operation that has suppressed your immune system

Have you taken any steroid medications in the past two years?

Do you have any blood disorders?

Anemia

Abnormally prolonged bleeding (e.g., hemophilla)

Have you ever required a blood transfusion?

Are you taking any blood thinners?

Do you have any artificial joints (hip, knee, shoulder, etc.)?

Have you ever been treated for glaucoma?

Have you ever had treatment for a tumor or cancer?

Radiation therapy involving the mouth, face, or neck

Chemotherapy

Do you smoke, or have you ever smoked?

Have you ever been treated for alcohol or other substance abuse?

Have you ever or do you currently use any recreational/illicit drugs?

Have you had a cold, flu, sore throat, sinus infection, or other respiratory tract infection in the past week?

Do you have any other concerns or diseases you think the doctor should know about?

Do you wish to talk with the doctor privately about anything?

WOMEN ONLY

Are you pregnant or trying to become pregnant?

Are you nursing (breastfeeding)?

Are you taking birth control pills?


Page 5 of 7

Financial Agreement

The following financial arrangements are available.
Please indicate your choice of payment by checking Option A, B, or C.

We appreciate your understanding and cooperation in completing the following information. If you have any questions concerning our financial policies, please do not hesitate to ask for our office manager.

OPTION A:

Payment is expected at time of treatment by

OPTION B:

If we are able to predetermine insurance coverage, you may know an estimate of your financial responsibility prior to surgery. If not, the exam fee cost and 20% of the total surgery/anesthesia/radiograph fee is due at the time of service. After your insurance company has made payment, the remainder of your balance is considered payable in full by you at that time. Options A (above) or C (below) are available to pay your balance.

Any overpayment by you or your insurance company will be refunded after the account has been paid in full.

Check here if you would like preauthorization or a pre-treatment estimate of coverage from your insurance company. Also, please make this known to the receptionist or the doctor. We will be happy to take care of this for you.

OPTION C:

Patients wishing to finance treatment fees may be eligible for payment plans/financing through CareCredit®. Please request details from the receptionist or office manager.

Please Note

  1. If 60 days have passed since your last payment, your account may be turned over to legal counsel and/or a collection agency for collection.

  2. A processing fee will be charged to all accounts turned over to legal counsel and/or a collections agency.

  3. A processing fee will be assessed to all accounts with returned checks.

  4. Accounts with returned checks may be turned over to legal counsel and/or a collection agency for collection.

 

As a courtesy to our patients, we will file insurance claims for you with the information you provided; however, our professional services are rendered to you and not to the insurance company. Therefore, you are directly responsible to us for the cost of your treatment. Your signature below hereby assigns all benefits to North Iowa Oral Surgery & Dental Implant Center that would otherwise be payable to you under the dental expense provision of the above-named dental insurance policies.

I agree to the financial plan outlined above and will be responsible for payment of all fees for treatment.


Page 6 of 7

Acknowledgement of Receipt of Statement of Privacy Practices

I acknowledge that I have received a copy of the Statement of Privacy Practices for the offices of North Iowa Oral Surgery & Dental Implant Center. The Statement 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 healthcare operations. The Statement of Privacy Practices also describes my rights and the responsibilities and duties of this office with respect to my protected health information. The Statement of Privacy Practices is also posted in the facility.

North Iowa Oral Surgery & Dental Implant Center reserves the right to change the privacy practices currently described in the Statement of Privacy Practices. If privacy practices change, I will be offered a copy of the revised Statement of Privacy Practices at the time of my first visit after the revisions become effective. I may also obtain a revised Statement of Privacy Practices by requesting that one be mailed or otherwise transmitted to me.

In addition to the allowable disclosures described in the Statement 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 healthcare information [PHI] cannot be shared with anyone unless otherwise allowed by HIPAA rules.)

Spouse Only

Any Member of My Immediate Family (e.g., Spouse, Children, Siblings, etc.)

Any Member of My Extended Family (e.g., Parents, Grandchildren, etc.)

Other


Page 7 of 7

COVID-19 Pandemic Dental Treatment Notice and Acknowledgment Risk

The World Health Organization has characterized the COVID-19 virus, also known as “coronavirus,” as a pandemic. Our practice wants to ensure you are aware of the risks of exposure to COVID-19 associated with receiving treatment during this pandemic.

COVID-19 is highly contagious and has a long incubation period. You or your healthcare providers may have the virus, not show symptoms, and yet still be highly contagious. In some patients, COVID-19 can result in a life-threatening respiratory disease. You may be exposed to COVID-19 at any time or in any place. 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 can create fine water spray or “aerosols” which may remain in the air for several minutes to hours. These aerosols may contain the COVID-19 virus and may create a risk of COVID-19 exposure. You cannot wear a protective mask over your mouth to reduce exposure during treatment as your healthcare providers need access to your mouth to render care. This leaves you vulnerable to COVID-19 transmission while receiving dental treatment.

To provide a safe environment for our patients and staff, this practice follows the applicable state and federal regulations and protocols for infection control, universal personal protection, and disinfection. However, due to the nature of the procedures we provide, it may not be possible to maintain social distancing between patients, doctors, and staff at all times.

 

PATIENT ACKNOWLEDGMENT

I acknowledge that I have read the Notice above and that I understand and accept that there is an increased risk of COVID-19 exposure with treatment during the pandemic.

I understand and accept the increased risk of COVID-19 exposure with treatment at this office.

I also acknowledge that I could, or may have, exposure to COVID-19 from outside this office and unrelated to my visit here.

I have read and understand the information stated above: