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El Dorado Hills
4420 Town Center Blvd, Ste 250
El Dorado Hills, CA 95762

Phone:
(916) 933-3332
Hours:
Mon-Fri: 8:00 AM–5:00 PM


Placerville
3168 Turner St, Ste 200
Placerville, CA 95667

Phone:
(530) 626-3300
Hours:
Mon-Fri: 8:00 AM–5:00 PM


Irvine
16300 Sand Canyon Ave, #711
Irvine , CA 92618

Phone:
(949) 727-7000
Hours:
Mon, Tues, Thur: 8:00 AM–5:00 PM
Wed, Fri: 8:00 AM–3:00 PM

Document Signers
    • 1 Signer 1

Page 1 of 5

Patient Registration Form


COVID-19 PANDEMIC - PATIENT DISCLOSURES

This patient disclosure form seeks information from you that we must consider before making treatment decisions in the circumstance of the COVID-19 virus.

A weak or compromised immune system (including, but not limited to, conditions like diabetes, asthma, COPD, cancer treatment, radiation, chemotherapy, and any prior or current disease or medical condition) can put you at greater risk for contracting COVID-19. Please disclose to us any condition that compromises your immune system and understand that we may ask you to consider rescheduling treatment after discussing any such conditions with us.

It is also important that you disclose to this office any indication of having been exposed to COVID-19, or whether you have experienced any signs or symptoms associated with the COVID-19 virus.

Do you have a fever or above normal temperature?

Have you experienced shortness of breath or had trouble breathing?

Do you have a dry cough?

Do you have a runny nose?

Have you recently lost or had a reduction in your sense of smell?

Do you have a sore throat?

Have you been in contact with someone who has tested positive for COVID-19?

Have you tested positive for COVID-19?

Have you been tested for COVID-19 and are awaiting results?

Have you traveled outside the United States by air or cruise ship in the last 14 days?

Have you traveled within the United States by air, bus, or train in the last 14 days?

I fully understand and acknowledge the above information, risks, and cautions regarding a compromised immune system

and have disclosed to my provider any conditions in my health history that may result in a compromised immune system. By signing this document, I acknowledge the answers I have provided above are true and accurate.


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PATIENT REGISTRATION

Do you have dental insurance?

INSURANCE

Primary

Secondary

Contact Info

Have you, or has any member of your family, been a patient prior to today?


ASSIGNMENT AND RELEASE

I hereby authorize the release of any medical/dental information necessary to process insurance claims. I also request payment of insurance benefits directly to True Oral, Facial & Dental Implant Surgery. I understand that payment for services is my responsibility, regardless of insurance coverage. I also understand a monthly service charge of 1.5% will be assessed to delinquent accounts over 90 days.


Page 3 of 5

HEALTH HISTORY

Have you been a patient in the hospital in the last 2 years?

Have you had any surgery or operation?

Are you allergic to soy products or eggs?

Are you allergic to any medications or drugs?

Are you currently taking any medications or drugs?

Are you or have you ever taken biphosphonate medications (such as Fosamax®)?

Are you pregnant?

Are you nursing?

Do you have a problem with motion sickness, or do you get sick to your stomach easily?

Have you, or has any member of your family, had problems with anesthesia?

Do you smoke or chew tobacco products?

Do you drink alcohol?

Do you wear contact lenses?

Rheumatic Fever

Heart Trouble

Recurrent Mouth Sores

Heart Murmer

Hip or Joint Implant

TMJ Disorder

Weight Loss Drugs

Jaundice

Liver Disease

Kidney Disease

Hepatitis

Stoke

High Blood Pressure

Tuberculosis

Latex Allergy

Asthma

Immunosuppressant

Drugs or Diseases

Emphysema

Diabetes

Seizures

Chronic Cough

Epilepsy

Chronic Fatique

Excessive Bleeding

Congenital Heart Problems

Psychiatric Drugs

Recreational Drugs

Have you had any illness not listed above?

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


Page 4 of 5

HIPAA CONSENT

I understand that, under the Health Insurance Portability & Accountability Act of 1996 (HIPAA), I have certain rights to privacy regarding my protected health information. I understand that this information can and will be used, but it is not mandatory for me to sign in order to:

• Conduct, plan, and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly or indirectly

• Obtain payment from third-party payers
• Conduct normal healthcare operations such as quality assesments and dental
certifications as well

I have been informed by you of your Notice of Privacy Practices containing a more complete description of the uses and disclosures of my health information. I have been given a copy of your Notice of Privacy Practices prior to signing this consent.

I understand that this office has the right to change its Notice of Privacy Practices from time to time and that I may contact this office at any time at the above address to obtain a current copy of the Notice of Privacy Practices.

I understand that I may request in writing that you restrict how my private information is used or disclosed to carry out treatment, payment, or health operations. I also understand you are not required to agree to my requested restrictions, but if you do agree then you are bound to abide by such restrictions. I understand that I may revoke this consent in writing at any time except to the extent that you have taken action relying on this consent.


Page 5 of 5

OFFICE POLICIES

Thank you for choosing True Oral, Facial & Dental Implant Surgery as your trusted oral surgery provider. Your dental health is very important to us. Please carefully read over our office policies listed on this form. If you have any questions, please ask a staff member upon check-in or by calling our office.

Insurance

Healthcare has entered an age of extreme complexity regarding the various insurance policies that each insurance company provides. Therefore, it has become necessary for our office to place the responsibility of understanding the requirements of your particular insurance plan on you.

• We request that you become familiar with your insurance benefits and prescription coverage prior to your appointment with our office. This includes knowing which facilities can be used for laboratory, hospitalization, or surgery.

• Keep in mind that insurance benefits and prescription coverage can change from year to year and plan to plan.

Financial

The patient or legal guardian is responsible for co-payments and co-insurance at time of service.

The patient or legal guardian is responsible for deductibles, non-covered services, and amounts that the insurance denies, regardless of the reason. Please become familiar with your insurance benefits prior to services being provided.

The patient or legal guardian will be held financially responsible if the insurance is not in effect at the time of the visit.

If there is a balance on your account, you will be sent a statement to the mailing address on file. If payment has not been received within 90 days of the first billed date, the account will be sent to our collection agency.

If the patient is a minor, whoever signs this form will be held financially responsible. No exceptions.

In divorce situations, financial responsibility will be with the guardian/parent that signs for the minor child. We will NOT invoice the absent parent. Payment in full will be required before the time of surgery date.