Please enable JavaScript in your browser to complete this form.Financial Policy Guidelines You are entitled to a clear understanding of your financial obligations before treatment is rendered. A wide variety of services are available in this office, therefore, we do not have a uniform policy that covers all procedures and treatments. PAYMENT IN FULL IS EXPECTED AT THE TIME SERVICE IS RENDERED. For your convenience, we do accept Visa, MasterCard, Discover and American Express. We also offer Care Credit financing for qualified patients. If time allows, we will check your insurance benefits at time of 1st visit. On subsequent visits, for procedures that are a covered expense under your insurance contract, you will be required to pay the portion not covered by insurance. We do not determine the amount of coverage you receive from your insurance company. If your insurance company has not paid the balance of your account within 45 days from the date of service, you will have 15 days to pay the balance. If your insurance company pays more than the balance due, we will send a refund check to you. You are responsible for any balance left after your insurance company has paid their portion. After completion of services, we will file your insurance for you and we will assist you in trying to receive maximum benefits.If you want a pre-determination of benefits, please make this request at the time of your consultation as this takes time to receive.Insurance is a contract between you and your insurance company. This office is NOT a part of this contract. We will file insurance claims as a courtesy to our patients. We will not become involved in disputes between you and your insurance company regarding what insurance considers as their “usual and customary charges”, deductibles, co-payments, covered charges, or secondary insurance, other than to supply factual information as necessary to the insurance company. You are ultimately responsible for the timely payment of your account. PLEASE BE READY TO PAY FOR TREATMENT RENDERED. You will be provided with an estimate of fees before the beginning of treatment. If you are unable to pay your portion of payment, we will schedule your treatment at another time. Patients who schedule and then cancel or reschedule (without notifying the office at least 24 hours in advance of the scheduled appointment) will be charged a fee of $25. Therefore, please be kind enough to call us if you will not be able to keep your appointment. I will be paying for today’s visit by: *CashCheckCredit/DebitBy my signature, I have read, or have had this form read to me, and I understand the financial guidelines of the office. *Clear SignatureDate: *PhoneSubmit Please enable JavaScript in your browser to complete this form.Health History Form Patient's Name: *Nickname:FemaleMaleAddress: *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeEmail: *Would you prefer e-mail over phone contact?YesNoHome Phone:Cell Phone:Birthdate:S.S #:Employer:Occupation:Business Address:City:Business Phone:Parent/Spouse's Name:Parent/Spouse's Birthdate:Parent/Spouse's S.S #:Parent/Spouse's Employer:Parent/Spouse's Occupation:Business Phone: Insurance InfoDental Insurance Company:Group #:Name of Insured:Relationship to Patient:In Case of Emergency (Closet Relative or Friend)Name:Phone:Physician:Phone:Pharmacy:Phone:Whom may we thank for referring you to our office?Health HistoryReason for present visit:Date of last dental visit:Have you ever had difficulties associated with dental treatment?YesNoIf yes, please explain:Do you fear dental treatment?YesNoAre you under the care of a physician? YesNoIf yes, who?Have there been any change in your general health in the last 5 years?YesNoIf yes, please explain:Date of last physical examination:Are you taking any medications?YesNoIf yes, please explain:Are you allergic to:Penicillin or other antibioticsDental anestheticsAspirinLatexOther drugs?If other, please explain:Have you had joint replacement?YesNoIf yes, please explain:Have you had heart/cardiac surgery?YesNoIf yes, please explain:Do you use tobacco?YesNo(Women) Are you pregnant?YesNoDue Date:Do you have or have you had any of the following:Rheumatic feverHigh Blood PressureAngina (chest pain upon exertion)Swelling anklesDiabetesAids or HIV PositiveGland problemsTuberculosisVenereal diseaseHeart DiseaseHeart valve problemsStomach ulcersProsthetic jointsSeizuresSinus TroubleLiver diseaseGlaucomaAnemiaA stroke or circulation problemsHeart murmurShortness of breathAllergiesHepatitisArthritisKidney problemsCancer or tumorsProlonged bleedingOther medical problems not listed above:To the best of my knowledge the provided medical dental history is correct. I consent to such examinations, x-rays, and diagnostic procedures and tests that may be prescribed. In addition, I consent to the performing of the dental and oral surgery procedures agreed to be necessary or advisable, including the use of general or local anesthetic and indicated photos, and releasing information to my insurance company. I will assume responsibility for fees associated with any dental treatment that I or my dependent receives.Patient's (Parents) Signature: *Clear SignatureDate: *EmailSubmit Please enable JavaScript in your browser to complete this form.Notice of Privacy Practices Acknowledgement 3 Rivers Cosmetic and Restorative Dentistry Jason B. Oyler, D.M.D., PC 2201 JL Todd Dr. NE Rome, Georgia 30165 706-235-1186I 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 to:• Conduct, plan and direct my treatment and follow-up among the multiple healthcare providers who may be involved in that treatment directly and indirectly • Obtain payment form third-party payers • Conduct normal healthcare operations such as quality assessments and physician certificationsI acknowledge that I have received you Notice of Privacy Practices containing a more complete description of the uses and disclosure of my health information. I understand that this is organization has the right to change it Notice of Privacy Practices from time to time and that I may contact this organization at any time at the address above 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 care 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.Patient Name *FirstLastPatient Signature: *Clear SignatureDate: *EmailSubmit Please enable JavaScript in your browser to complete this form.Patient Health Form Patient's Name: *Birthdate: *S.S #:Address: *Address Line 1CityAlabamaAlaskaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaOhioOklahomaOregonPennsylvaniaRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahVermontVirginiaWashingtonWest VirginiaWisconsinWyomingStateZip CodeHome Phone:Cell Phone:Email: *Date:Do you have or have you had any of the following:AllergiesAnemiaAnesthetics AllergyAnginaArthritisArtificial Joints Aspirin AllergyAsthmaBisphosphonatesClindamycin AllergyCodeine Allergy Congestive Heart FailureCoumadin PatientCirculation ProblemsDefibrillator (heart)Demerol Allergy DiabetesDuracef Allergy EpilepsyEpinephrine AllergyErythromycin AllergyFibromyalgiaGlaucomaHead InjuriesHeart DiseaseHeart Murmur Heart murmurHepatitisHigh Blood PressureHeart Valve problemsHerpesHIVJaundiceKidney problemsLatex AllergyLiver DiseaseMorphine AllergyMVPNervous DisordersPacemakerPenicillin AllergyPercocet AllergyPre-MedicateRadiation treatmentRespiratory problemsRheumatic Fever RheumatismSeizuresSinus problemsSleep ApneaStomach problems Sulfa AllergyStents placed StrokeThyroid problemsTuberculosisTumorsTylox allergyUlcersVenereal DiseaseTrauma to face or head injuryHave you been hospitalized in the past year? If so, for what?Please list all medications you are currently taking:MessageSubmit
