Folsom Oral Surgery And Implant Center
Gregory G. Olsen, DDS, FICOI
Diplomate of the American Board of Oral and Maxillofacial Surgery
Diplomate of the National Dental Board of Anesthesiology
2370 E. Bidwell, Suite 130 - Folsom, CA 95630
Tel: 916-983-6637 - Fax: 916-983-6610 - www.folsomdentalimplants.com

Patient Information:

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Male Female
Full-Time Part-Time
Yes No
Emergency Contact
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Person Financially Responsible:

Use Patient Information
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Self Spouse Father Mother Other
 

Insurance Information:

Primary Dental Insurance Company Name
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Self Spouse Father Mother Other
Secondary Dental Insurance Company Name
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Self Spouse Father Mother Other
Medical Insurance Company Name
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Self Spouse Father Mother Other

Statement of Financial Responsibility:

I agree to be financially responsible for all services rendered by the treating dentist. A payment on account or an insurance co-payment may be due at the time services are rendered. I will be financially responsible for all charges not covered by my insurance company. I agree to pay all financial obligations in a timely fashion. I accept that all delinquent accounts will bear interest at the rate of 18% per annum (1.5% per month), but that special financial arrangements can be made in certain circumstances.

I understand that a percentage of my surgery may be covered under my dental or medical insurance plan. I understand that all efforts will be made to determine benefits and co-payment information prior to my treatment. I understand that I will be responsible for all co-payments, deductibles, and non-covered procedures on or before the day of surgery. In the event that the insurance company denies a claim after a procedure has been completed, I understand that I am responsible for the balance on the account.

We are happy to assist you in filing the necessary forms to help you receive the full benefit of your dental coverage. Insurance policies vary greatly; therefore please understand that we can only estimate your insurance coverage in good faith. The insurance relationship constitutes an agreement between the carrier, employer and the patient. As such, we can make no guarantee of the estimated coverage or insurance payment. Please know that we will do everything within reason to see that you receive the full benefits of your policy.

Assignment of Insurance Benefits: I hereby authorize and request my insurance company to pay directly to the Doctor the amount due on my claim for services rendered to me or my dependent. I further agree that should the amount be insufficient to cover the entire medical and surgical expense. I will be responsible for payment of the difference, and if the nature of the disability be such that it is not covered by the policy, I will be responsible to Folsom Oral Surgery And Implant Center for payment of the entire bill.

Yearly Update:

Medical History:

In the following questions, check YES or NO, whichever applies to you. Your answers are for our records only and will be considered confidential. Thank you.
1.Has there been any change in your general health within the past year?
2.When was your last physical exam?
3.Are you now under the care of a physician?
4.Have you had a serious illness or operation(s)?
5.Have you been hospitalized or had serious illness within the past five (5) years?
6.Do you have, or have you had, any of the following problems or diseases?
a.Rheumatic fever or hrheumatic heart disease
b.Congenital heart lesions or heart murmurs
c.Cardiovascular disease (chest pains, angina, heart attack, coronary insufficiency, coronary occlusions)
d.Stroke, hardening of the arteries, arteriosclerosis
e. High or Low blood pressure
f.Bleeding problems or bruising easily
g.Asthma
h.Shortness of breath
i.Tuberculosis or emphysema
j.Persistent cough, coughing up blood
k.Diabetes
l.Fainting spells, seizures, dizziness
m.Hepatitis, jaundice, or liver disease
n.Sinus problems
o.Hay fever
p.Headaches
q.High or low thyroid symptoms
r.HIV positive, AIDS, or ARC
s.Venereal disease (gonorrhea, syphilis)
t.Herpes / cold sores
u.Dry mouth, excessive thirst
v.Glaucoma, eye disease, blurred vision
w.Arthritis, rheumatism, joint pain, stiffness
x.Kidney / bladder disease, difficult or frequent urination, blood in urine
y.Stomach ulcers, problems
z.Tumors, cancer
aa.Anemia
bb.Sleep apnea
cc.Emotional or psychiatric problems
7.Do you have, or have you had, any of the following?
a.Radiation treatments or chemotherapy
b.Artificial joint(s)
c.Prosthetic heart valve or pacemaker
d.Blood transfusions or abnormal bleeding
8.Are you taking, or have you taken, the following in the last year?
a.Antibiotics or Sulfa drugs
b.Anticoagulants or blood thinners (Coumadin / Plavix)
c.Aspirin
d.Digitalis
e.Nitroglycerin
f.Medicine for high blood pressure
g.Cortisone or steroids
h.Antihistamines
i.Insulin or diabetes medications
j.AZT or other Anti-Retroviral
k.Fosamax, Boniva, Zometa, Aredia or any other "Bisphosphonate" drug
l.Tranquilizers
m.Diet pills
n.Natural supplements
o.Recreational drugs
p.LIST ALL MEDICATIONS YOU ARE CURRENTLY TAKING
q.Please list any medicine, drug, food, or material that you are ALLERGIC to (e.g. latex, Penicilin, etc.)
9.Do you have any disease, condition, or problem not listed above?
10.Have you, or any family member, had trouble with general anesthesia (i.e. malignant hyperthermia)?
11.Do you smoke and/ or vape?
13.Why have you come to see us today?

Women:

14.Are you pregnant?
15.Are you breast feeding an infant?
16.Are taking oral contraceptives (birth control pills)?

Signatures:

To the best of my knowledge, I have answered every question completely and accurately. I will inform my dentist of any change in my health and / or medications.

I consent to the taking of clinical photos in the course of diagnostic and surgical procedures for use of treatment, educational, or research purposes.

I authorize the release of any medical or other information necessary to process insurance claims and I authorize payment of benefits to the treating physician / dentist for the services provided. I also request payment of government benefits (Medicare) to the treating physician / dentist.

HIPPA Compliance Statement: (found under HIPPA/Privacy Policy)
I acknowledge that I have read a copy of the office's NOTICE OF PRIVACY PRACTICES AND RIGHTS. I have read the notice and I understand my right and the office's privacy policies.
Patient refuses to sign the notice. Employee name and date:
The patient is unable to sign the acknowledgement or is a minor. If the patient is a minor or represented by a personal representative, the authorized guardian / representative has signed below.
Patients 18 and over. "I give permission to discuss any medical information related to my treatment to the following individual(s):"