Document

REGISTRATION

First

Last Name

MI

Street Address

Phone No.

Email

City

State

Zip Code

Date of Birth

License No.

SSN

Marital Status

Student Status

Sex

Employer

Emergency Contact

Person With

Relationship

Phone
IF PATIENT IS UNDER 19, PARENT MUST FILL THIS OUT

First Name

Last Name

Middle Initial

Relation To Patient

Address

City, State, Zip

Home

Work Phone

Cell Phone

Date of Birth

SSN

License

Responsible Party Employer

Address of Employer

City, State, Zip

Student Status
PRIMARY MEDICAL INSURANCE INFORMATION FORM

Insurance ID

Group No.

Military Pay Grade

Name of Insured

Insurance Company Name

Insured SSN

Insured DOB

Insured Employer

Insurance Co. Address

City, State, Zip

Relationship to Patient
PRIMARY DENTAL INSURANCE INFORMATION FORM

Insurance ID

Group No.

Military Pay Grade

Name of Insured

Insurance Company Name

Insured SSN

Insured DOB

Insured Employer

Insurance Co. Address

City, State, Zip

Relationship to Patient
MEDICAL HISTORY FORM

Are you under a physician's care?

Yes No

Explain

Have you been hospitalized or had a major operation?

Yes No

Explain

Have you problems under anesthesia?

Yes No

Explain

Do you use tobacco?

Yes No

Explain

Do you use controlled substances?

Yes No

Explain

Please list any medications you are taking:

Are you:

Allergic to:

Explain:

Who is your general dentist?
DO YOU OR HAVE YOU HAD THE FOLLOWING:

AIDS/HIV
Yes No

Alzheimers
Yes No

Anaphylaxis
Yes No

Anemia
Yes No

Angina
Yes No

Asthma
Yes No

Bruise Easily
Yes No

Cancer
Yes No

Chemotherapy
Yes No

Chest Pains
Yes No

Convulsions
Yes No

Diabetes
Yes No

Drug Addiction
Yes No

Easily Winded
Yes No

Emphysema
Yes No

Excessive Bleeding
Yes No

Excessive Thirst
Yes No

Frequent Cough
Yes No

Frequent Headache
Yes No

Genital Herpes
Yes No

Glaucoma
Yes No

Hay Fever
Yes No

Heart Attack/ Failure
Yes No

Arthritis or Gout
Yes No

Artificial Joint
Yes No

Blood Transfusion
Yes No

Blood Disease
Yes No

Artificial Heart Valve
Yes No

Breathing Problems
Yes No

Frequent Diarrhea
Yes No

Cold Sores/Fever Blisters
Yes No

Congenital Heart Disorder
Yes No

Cortisone Medicine
Yes No

Epilepsy or Seizures
Yes No

Fainting or Dizziness
Yes No

Heart Murmur
Yes No

Heart Pace Maker
Yes No

Heart Trouble/ Disease
Yes No

Hemophilia
Yes No

Hepatitis A
Yes No

Hepatitis B or C
Yes No

Herpes
Yes No

High Blood Pressure
Yes No

Hives or Rash
Yes No

Hypoglycemia
Yes No

Irregular Heartbeat
Yes No

Kidney Problems
Yes No

Leukemia
Yes No

Liver Disease
Yes No

Low Blood Pressure
Yes No

Lung Disease
Yes No

Mitral Valve Prolapse
Yes No

Pain in Jaw Joints
Yes No

Parathyroid Disease
Yes No

Psychiatric Care
Yes No

Radiation Treatments
Yes No

Recent Weight Loss
Yes No

Renal Dialysis
Yes No

Rheumatic Fever
Yes No

Rheumatism
Yes No

Scarlet Fever
Yes No

Shingles
Yes No

Sickle cell Disease
Yes No

Sinus Trouble
Yes No

Spina Bifida
Yes No

Stomach or Intest Dis
Yes No

Stroke
Yes No

Swelling of Limbs
Yes No

Thyroid Disease
Yes No

Tonsilitis
Yes No

Tuberculosis
Yes No

Tumors or Growths
Yes No

Ulcers
Yes No

Venereal Disease
Yes No

Yellow Jaundice
Yes No
FINANCIAL POLICY (SIGNATURE REQUIRED)

POLICY: Payment for services rendered is due in full at the time of service. Our office accepts cash, debit cards, and credit cards (Visa & Mastercard). Due to the large number of returned checks, we are no longer accepting personal checks. FOR PATIENTS WITH INSURANCE: As a service to our patients, we will verify insurance beneffts and collect what your insurance will not pay on the day of surgery. Every effort will be made to closely ESTIMATE your co-payments and deductibles whlch are due at the time of service, but the ultimate responsibility for any unpaid balance rests on you. We will make every effort to contact you by phone with an ESTIMATE but it is ultimately your responsibility to contact our office if you have not heard from us before your surgery. PLEASE UNDERSTAND THAT INSURANCE IS A CONTRACT BETWEEN YOU AND YOUR INSURANCE COMPANY. If an Insurance carrier has not paid within 60 days of billing, any unpaid professlonal fees are due and payable in full by you. You will be responsible for outside lab services. The lab will send a separate statement. MANAGED CARE PARTICIPANTS: Some benefit plans require pre-authorization and specialist referral forms from your primary physician. Please provide the proper Insurance plan identification and forms necessary to process your claims on the day of consultation. All co-payments or patient out-of-pocket fees are due and payable at the time of service SURGERY FEES: All co-payments, deductibles, and payments for non-covered surgical procedures are due prior to your surgery. (To assist our patients, we offer alternative financing sources. Please inquire with the patient representative.) WORKERS COMPENSATION: If your injury is work-related, we require the necessary insurance billing information and employer authorization form prior to your office visit or treatment. PERSONAL INJURY CASES: This office does not accept liens nor bill for auto- accident or other liability or lawsuit related cases. The patient is responsible for services provided at the time of service. CANCELLATION OR NO-SHOW APPOINTMENTS: Please give 24-hour notice if you are unable to keep your appointment. A $100.00 fee will be charged for any broken surgical appointment not canceled 24 hours in advance. The practice reserves the right to dismiss patlents with excessive cancelled appointments. SIGNATURE ON FILE: I request payment of authorized insurance benefits to be made on my behalf to METRO ORAL & MAXILLOFACIAL SURGERY for services provided me by listed facility and/or physician.

I understand that if my account becomes delinquent it will be placed with Prim and Mendheim LLC. I also agree and consent to the following terms regarding any outstanding balance that I owe: (1) I will Incur interest on the balance due at the rate of 1 and 12 percent per month (18% PER ANNUM); (2) I will be responsible for reasonable collection costs and attorney's fees in and costs of court incurred by this office in the collection of same, whether such outstanding balance is satisfied prior to, after initiation of a lawsuit, or after a judgment has been issued in a lawsuit; and (3) I agree and hereby consent that any lawsuit and/or legal proceeding surrounding any outstanding balance and/or debt that I owe, and fees and costs thereon, shall be initiated and litigated in the court of appropriate jurisdiction of Houston County, Alabama, and I hereby waive any and all defenses and/or objections to said jurisdiction and waive all rights to claim exemption. I affirmatively consent to and agree not to claim any and all personal property, homestead, and /or wage exemptions, in particular that certain wage exemption contained in article X of the State of Alabama Constitution of 1901, that I may be entitled to, whether the said exemption be statutory and/or constitutional in nature, and waive any and all defenses thereto. I further agree that if a cell phone number has been provided I can be contacted regarding my balance on sald cell phone. Additionally, if I reside in Florida, I agree to waive my rights to any exemption that would prohibit a wage garnishment should same become necessary to secure payment of any outstanding balance. I also agree that at any time my balance has not been paid as I have agreed herein that my credit history will be investigated and thoroughly reviewed. By signing below, I consent to the foregoing terms and affir atively acknowledge that I have read, or have been provided adequate time to read, the foregoing before signing below.

PATIENT'S/LEGAL GUARDIAN SIGNATURE
PLEASE SIGN

To the best of my knowledge, the questions on this form have been accurately answered. I understand that providing incorrect information can be dangerous to my (or patient's) health. It is my responsibility to inform this office of any changes in medical status. I have been given the opportunity to read and ask questions about the Health Information Privacy Practices on this office. I understand I am financially responsible for charges incurred in this office. I further understand that any charges not covered by my insurance company will be my financial obligation.

PATIENT'S/LEGAL GUARDIAN SIGNATURE