Step 1 of 7 14% Date PATIENT INFORMATION:Patient first namePatient middle initialPatient last nameSexMaleFemaleAgeBirth date Social security numberPhone numberSecondary phone numberEmail address AddressCityStateWashingtonAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZipEmployer or school if the patient is a studentCity of employer or schoolDentist namePhysician nameOrthodontist nameOther specialist EMERGENCY CONTACT:Name of emergency contactRelationship to patientPhone number of emergency contactSecondary phone number of emergency contact RESPONSIBLE PARTY:Person financially responsible for the account:PatientOtherFull name of responsible partyBirth date of responsible party Social security number of responsible partyPhone number of responsible partySecondary phone number of responsible partyAddress of responsible partyCity of responsible partyState of responsible partyWashingtonAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces PacificZip code of responsible partyEmployer of responsible partyCity of responsible partys employer DENTAL INSURANCE INFORMATION:Primary Dental Insurance:Primary dental insurance companyPrimary dental insurance group numberName of primary dental insurance subscriberPrimary dental insurance subscribers relationship to patientPrimary dental subscribers employerSocial security number of primary dental insurance subscriberBirth date of primary dental insurance subscriber Secondary Dental Insurance:Secondary dental insurance companySecondary dental insurance group numberName of secondary dental insurance subscriberSecondary dental insurance subscribers relationship to patientEmployer of secondary dental subscriberSocial security number of secondary dental insurance subscriberBirth date of secondary dental insurance subscriber MEDICAL INSURANCE INFORMATION:Primary Medical Insurance:Primary medical insurance companyPrimary medical insurance group numberName of primary medical insurance subscriberPrimary medical insurance subscribers relationship to patientPrimary medical insurance subscribers employerSocial security number of primary medical insurance subscriberBirth date of primary medical insurance subscriber Secondary Medical Insurance:Secondary medical insurance companyGroup number of primary medical insuranceName of secondary medical insurance subscriberSecondary medical insurance subscribers relationship to patientEmployer of secondary medical insurance subscriberSocial security number of secondary medical insurance subscriberBirth date of secondary medical insurance subscriber Medical HistoryALLERGIES:Are you sensitive or allergic to:Penicillin?YesNoNovocaine?YesNoAspirin?YesNoCodeine?YesNoRubber or latex?YesNoPlease list all other known allergies:MEDICATIONS:Please list all current medications of any kind including dosage: Medical HistoryAre you in good health?YesNoHas there been any change in your general health in the past year?YesNoDate of last physical exam Are you under a physicians care or have you been in the past five years including hospitalizations or surgeries?YesNoList prior operations or surgeries and hospitalizations:Have you taken Cortisone or other steroids in the past 24 months?YesNoHave you had ophthalmic or eye surgery in the past 8 weeks?YesNoHave you or your family had a reaction to dental or general anesthetic?YesNoHave you had any adverse effects from dental treatment?YesNoDo you ever have to stop because of pain in your chest or shortness of breath or because you feel very tired?YesNoHave you ever taken bisphosphonate medications?YesNoDo you take or have you ever taken angiotension converting enzyme inhibitor or ACE inhibitor?YesNo Medical History (cont)Have you had or do you currently have:Heart disease or attack?YesNoAngina pectoris or chest pain?YesNoHigh blood pressure?YesNoHeart murmur?YesNoRheumatic fever?YesNoCongenital heart defect or lesion?YesNoArtificial heart valve?YesNoHeart pacemaker?YesNoHeart surgery or transplant?YesNoStroke?YesNoAneurysm?YesNoOther cardiovascular problem?YesNoDescribe the problem pleaseHEMATOLOGICALBlood transfusion?YesNoAnemia?YesNoHemophilia?YesNoLeukemia?YesNoSickle cell anemia disease?YesNoTendency to bleed longer than normal or bruise easily?YesNoNEURAL / SENSORYEye pain?YesNoVision problems or contact lenses?YesNoGlaucoma or cataract?YesNoEaraches or ringing in the ears?YesNoHearing loss?YesNoSevere headaches?YesNoFainting or dizzy spells?YesNoEpilepsy or seizures or convulsions?YesNoNervousness?YesNoPsychiatric treatment?YesNoGASTROINTESTINALStomach or intestinal ulcers?YesNoGastritis?YesNoColitis?YesNoPersistent diarrhea?YesNoHepatitis?YesNoLiver disease?YesNoYellow jaundice?YesNoCirrhosis?YesNoRESPIRATORYHay fever?YesNoSinus trouble?YesNoAllergies or hives?YesNoAsthma?YesNoChronic cough?YesNoEmphysema or pneumonia?YesNoTuberculosis or TB?YesNoBreathing difficulties?YesNoDERMAL / SKIN / JOINTSSkin rash?YesNoDark moles which recently changed in appearance?YesNoNight sweats?YesNoSore muscles?YesNoStiff joints?YesNoArthritis?YesNoArtificial joint?YesNoFever blisters?YesNoMouth ulcers or canker sores?YesNoColored or discolored areas in mouth?YesNoENDOCRINEDiabetes?YesNoThyroid disease?YesNoURINARYUrinate frequently?YesNoKidney or bladder problems?YesNoSyphilis or gonorrhea or chlamydia or genital herpes or any other sexually transmitted disease?YesNoOTHER CONDITIONSFrequent sore throat?YesNoEnlarged lymph node or gland?YesNoUse tobacco or chew or smoke?YesNoDrink alcohol?YesNoDrug use?YesNoTumor or cancer?YesNoChemotherapy?YesNoRadiation treatment?YesNoHistory of jaw joint problems such as clicking or locking or pain?YesNoDo you have any other disease or medical conditions the doctor should know about?Do you wish to talk to the doctor about anything privately?YesNoWOMEN:Are you pregnant or is there a possibility of being pregnant?YesNoDo you wish to have a pregnancy test?YesNoAre you nursing?YesNoAre you taking birth control pills?YesNo Office Policy Regarding Payment for Treatment I understand that Todd Cooper, DDS, Tyson Teeples, DMD, MD, and Ryan Toponce, DMD utilize the trade name Columbia Basin Oral & Maxillofacial Surgeons at 512 North Young Street, Kennewick, WA 99336 PAYMENT PLANS AVAILABLE:I understand that payment is expected at the time services are rendered. I will pay according to the method indicated, please initial one:1. I will pay ALL fees at the time of treatment by cash, check, Visa, or MasterCard.2. For insurance coverage: I will pay the amount quoted to me as my estimated co-payment at the time of treatment with the following agreement: 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 understanding 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. THERE IS A SERVICE CHARGE OF 1.5% PER MONTH ASSESSED ON ANY ACCOUNT BALANCE OVER 60 DAYS WITH A MINIMUM CHARGE OF $1.00 PER MONTH.Notice of Privacy Practices: Please InitialI have received a copy of this office’s Notice of Privacy Practices. You may contact me and leave messages by phone, mail, or email.You may discuss my account, insurance, or treatment with:Spouse, Parent, etc.