• • •

Dear New Patient,

We have enclosed your new patient paperwork with this letter. Please complete the

forms in their entirety. Please bring the paperwork with you to your appointment on

@ .

On the day of your appointment, please bring with you:

• Your insurance cards for both medical and dental.

• Photo identification (preferably driver’s license).

• A list of all prescription medicines and over the counter medicines you are

taking.

Due to limited waiting room space, please arrive no earlier than 15 minutes before your

appointment. Please understand that we are a surgery office and try to run on time but

emergencies do happen.

Thank you for choosing Ryan Green MD, DDS as your Oral Surgeon, and we look forward to

meeting you. If you have any questions prior to your appointment, call us at (325) 232-8939.

Thank you.

PATIENT REGISTRATION

NAME______________________________________________________________________DATE____________________________ DOB______________________ AGE__________________ SEX (male) (female) MARITAL STATUS (M) (S) (D) SS#__________________________________________ E-MAIL ADDRESS________________________________________________ ADDRESS____________________________________________________________________________________________________ Street City State Zip Code PHONE NO. ( )_________________ ( )_________________ ( )__________________ ( ) _____________________ Home Work Cell Other EMPLOYER__________________________________________________________________________________________________ Name Address Phone no. PARENT/LEGAL GUARDIAN (if minor):_________________________________________PHONE:______________________________ WHOM MAY WE THANK FOR REFERRING YOU? (dentist, physician, friend, etc.) ____________________________________________ CONTACT PERSON NOT LIVING WITH YOU__________________________________________________________________________ Name Phone no.

WOULD YOU LIKE FOR US TO BILL YOUR INSURANCE? □ YES □ NO

PRIMARY DENTAL INSURANCE PRIMARY MEDICAL INSURANCE

INS. CO.__________________________________________ INS. CO.___________________________________________

ADDRESS_________________________________________ ADDRESS__________________________________________

_________________________________________________ _________________________________________________

PHONE NO._______________________________________ PHONE NO.________________________________________

GROUP #_________________________________________ GROUP # __________________________________________

INSURED’S NAME__________________________________ INSURED’S NAME___________________________________

RELATION__________________SS#____________________ RELATION_____________SS#_________________________

INSURED’S EMPLOYER_______________________________ INSURED’S EMPLOYER_______________________________

INSURED’S DATE OF BIRTH____________________________ INSURED’S DATE OF BIRTH____________________________

PERSON RESPONSIBLE FOR THIS ACCOUNT______________________________________________________________________ ADDRESS________________________________________________________________ PHONE NO._______________________ RESPONSIBLE PARTY’S SS#_________________________ DOB______________________ DL#______________________

I HEREBY AUTHORIZE DR. RYAN GREEN TO PERFORM THE SERVICES THAT ARE NECESSARY IN HIS JUDGEMENT AND ANY ADDED PROCEDURE WHICH HE MAY DEEM NECESSARY FOR THE ABOVE PATIENT.

____________________________________________________________________________________________________________________ PATIENT'S SIGNATURE OR PARENT OR GUARDIAN'S SIGNATURE (if applicable)

PATIENT HEALTH HISTORY

Patient’s Name Date of Birth Height Weight Date

Answer all questions by circling Yes (Y) or No (N) All responses are kept confidential

1. Are you in good health? ................................................ Y N 2. Has there been any change in your

general health in the past year? .................................... Y N 3. Date of last physical exam 4. Are you now under a physician’s care for

a particular problem?..................................................... Y N 5. Have you ever had any serious illnesses,

operations or hospitalizations? If so, describe: ............. Y N

6. DO YOU HAVE OR HAVE YOU EVER HAD:

A. Rheumatic Fever or Rheumatic Heart Disease? .... Y N B. Congenital Heart Disease? .................................... Y N C. Cardiovascular Disease (Heart Attack, Heart

Trouble, Heart Murmur, Coronary Artery Disease, Angina, High Blood Pressure, Stroke, Palpitations, Heart Surgery, Pacemaker)? ................................. Y N

D. Lung Disease (Asthma, Emphysema, COPD, Chronic Cough, Bronchitis, Pneumonia, Tuberculosis, Shortness of Breath, Chest Pain, Severe Coughing)? ............................................................ Y N

E. Seizures, Convulsions, Epilepsy, Fainting or Dizziness? .............................................................. Y N

F. Bleeding Disorder, Anemia, Bleeding Tendency, Blood Transfusion? Do you bruise easily? ............ Y N

G. Liver Disease (Jaundice, Hepatitis)? ...................... Y N H. Kidney Disease? .................................................... Y N I. Diabetes? ............................................................... Y N J. Thyroid Disease (Goiter)? ...................................... Y N K. Arthritis? ................................................................. Y N L. Stomach Ulcers or Colitis? ..................................... Y N M. Glaucoma? ............................................................. Y N N. Osteoporosis? ........................................................ Y N O. Implants placed anywhere in your body

(Heart Valve, Pacemaker, Hip, Knee)? .................. Y N P. Radiation (X-ray) treatment for Cancer? ................ Y N Q. Clicking or popping of jaw joint, pain near ear,

difficulty opening mouth, grind or clench teeth? ..... Y N R. Sinus or Nasal problems? ...................................... Y N S. Any disease, drug or transplant operation

that has depressed your immune system? ............. Y N T. Sleep apnea?.......................................................... Y

N

7. ARE YOU USING ANY OF THE FOLLOWING:

A. Antibiotics? ............................................................. Y N B. Anticoagulants (Blood Thinners)? .......................... Y N C. Aspirin or drugs such as Motrin, Aleve, Ibuprofen? Y N D. High Blood Pressure medications? ........................ Y N E. Steroids (Cortisone, Prednisone, etc.)? ................. Y N F. Tranquilizers?......................................................... Y N G. Insulin or Oral Anti-Diabetic drugs? ........................ Y N H. Digitalis, Inderal, Nitroglycerin or other heart drug? Y N

I. Are you taking or have you ever taken Bisphospho- nates for osteoporosis, multiple myeloma or other

cancers (Reclast, Fosamax, Actonel, Boniva, Aredia, Zometa, Prolia) ? ...................................... Y N

J. Have you ever been advised not to take a medication? ............................................................................... Y N K. Please list any and all medications taken, including

prescription medications, diet drugs, over-the-counter medications, herbal or holistic remedies, vitamins or minerals:

8. ARE YOU ALLERGIC TO OR HAVE YOU HAD AN ADVERSE REACTION TO:

A. Local Anesthesia (Novacain, etc.)? ........................ Y N B. Penicillin or other antibiotics? ................................. Y N C. Sedatives, Barbiturates?......................................... Y N D. Aspirin or Ibuprofen? .............................................. Y N E. Codeine or other pain killers? ................................. Y N F. Latex or Rubber products? ..................................... Y N G. Metal of any kind? .................................................. Y N H. Chemicals or jewelry (rash or sensitivity)?.............. Y N I. Food products? ....................................................... Y N J. Other allergies or reactions? Please list ................ Y N

9. Do you smoke or chew Tobacco? .................................. Y N How much per day? 10. Is there any past history of Alcohol or Chemical

Dependency or Emotional Disorder that may affect the care we provide you? ............................................... Y N

11. Have you had any serious problems associated with any previous dental treatment?...................................... Y N

12. Have you or an immediate family member had any problem associated with intravenous anesthesia?......... Y N

13. Do you have any other disease, condition or problem not listed above that you think the doctor should know about? ....................................................... Y N

14. Do you wish to talk to the doctor privately about anything? ............................................................. Y N

15. Have you ever had a bone density scan? ..................... Y N 16. FOR WOMEN ONLY

A. Are you Pregnant, or is there any chance

you might be Pregnant?.......................................... Y N B. Are you nursing? .................................................... Y N C. If you are using Oral Contraceptives, it is important

that you understand that antibiotics (and some other medications) may interfere with the effectiveness of oral contraceptives. Therefore, you will need to use mechanical forms of birth control for one complete cycle of birth control pills, after the course of antibiotics or other medication is completed. Please consult with your physician for further guidance.

I understand the importance of a truthful and complete Health History to assist my doctor in providing the best care possible. I have had the opportunity to discuss my Health History with my doctor. ______________ _______________________________________ ________________________________________ Date Signature Signature of Person Completing Form (if other than patient)

Oral & Implant Surgery of Abilene

Ryan Q. Green, MD, DDS

Acknowledgement of Receipt of Summary of Notice of Privacy Practices

I acknowledge that I have the option to request a copy of the Summary of Oral & Maxillofacial Surgery of Abilene

Notice of Privacy Practices memo. I am also aware that a full-length copy will be made available to me upon request.

I understand that Oral & Maxillofacial Surgery of Abilene may use and disclose medical information to contact me

regarding future appointments with the Practice. This contact may be made via either electronic and/or written

communication. I am aware these methods could potentially be received and/or intercepted by others. To restrict a

method, please circle the one(s) above you would like us to use to contact you.

_______________________________________ ___________________________________________ Patient’s Name (Please Print) Patient (Or legal guardian) Signature _______/_______/_______ Date I understand that it is the policy of Oral & Maxillofacial Surgery of Abilene to restrict access to my Protected Health

Information. In addition to the caregiver(s) providing health services, or my insurance company(ies) for payment of

my claim, I would like the following people to have access to my Protected Health Information.

Name Date of Birth All or Restricted* 1______________________________________________________________________________________ 2______________________________________________________________________________________ 3______________________________________________________________________________________ *Restricted Clinical Information: If you stated “restricted” to the above, please specify what clinical information you DO NOT wish to share with the person(s) listed: _______________________________________________________ ______________________________________________________________________________________________

This authorization will remain in effect until terminated by the patient or patient’s representative(s). State law permits both parents to have access to patient health information UNLESS we are provided a COURT order restricting this right.

IF THE PATIENT IS UNDER THE AGE OF 18, A PARENT OR LEGAL GUARDIAN MUST SIGN THIS ACKNOWLEDGEMENT. Thank you.

Oral & Implant Surgery of Abilene Ryan Q. Green, MD, DDS

FINANCIAL POLICY for Dental Procedures

Your health and well being are our primary concern. We feel that we provide the highest quality of oral and maxillofacial surgery available to our patients. Therefore, we feel it is important for our patients to fully understand their treatment plan, the fees involved and the method of payment. In order to avoid any misunderstanding, we wish to explain our office policy regarding payment of fees. Dr. Green is an independent health practitioner. He is not employed or contracted by any dental insurance company. Your insurance plan is a contract between you, your employer, and the insurance company. You have signed a contract with your insurance company, and therefore any benefits to which you are entitled will be settled between the company and you. It is your responsibility to know your coverage and benefits.

Our office policy requires that payment be made at the time services are rendered for all dental

procedures. All office visits must be paid in full at the time of service regardless of insurance. As a

courtesy, we will help you file your claim. With some insurance claims having to go medical and dental

we ask that you please be understanding through the process. For your convenience we accept cash,

money orders, and credit card payment (MasterCard, Visa, and Discover). We do not accept personal

checks. CareCredit is available to all patients needing a financing option. We do not offer in-house

payment plans.

Signature __________________________________________________ Date _____________________

I have read and understand the financial policy as stated above. I agree to meet my financial obligation in accordance with this policy. Should I have any questions I will contact the Insurance Specialist responsible for my account at (325) 232-8939. Signature __________________________________________________ Date _________________

Oral & Implant Surgery of Abilene Ryan Q. Green, MD, DDS

INSURANCE POLICY Our office is an out of network provider. Depending on your insurance company, we may be able to figure costs and file the claim on your behalf. This is a courtesy to our patients to help minimize financial burden when possible. If we are able to file your insurance, please read the below guidelines. Our goal is to make the process transparent and easy to understand.

1. Please make sure you present your dental insurance card, not your medical insurance card. 2. If you do not have a card for your dental insurance, please provide us with Group number, ID

number, filing address, claim phone number.

We will need the following information in order to file your insurance. We cannot file your insurance without all of this information and without the correct information.

The patient legal name (as it appears on legal documents, such as your driver’s license)

Patient birthdate – please double check for accuracy

Patient social security number – please double check for accuracy

Subscriber legal name (exactly as it appears on insurance card). The subscriber is the main person

in your family who the insurance policy goes through.

Subscriber birthdate – please double check for accuracy

Subscriber social security number – please double check for accuracy

Subscriber address – this is the address that the insurance company will have on file

If the policy is through an employer, we will need the name of the employer that is listed on the

card and the group number.

If any of the above information is presented incorrectly, your insurance company will mark the claim as “unprocessed”. This means if you call your insurance company, they will have no record of the claim because the information was not correct. This is why we must receive accurate information. If all of the information given is correct, it can take up to 12 weeks for our office to receive payment. If the insurance company requests additional procedure information from our office, it could take up to 20 weeks to receive payment. If your policy requires the claim to be sent to medical insurance first, it could take up to a year for us to receive payment. Please remember the most important factor of this process is communication. Our office is out of network provider and we file and figure insurance as a courtesy to our patients. Thank you.

Patient / Guardian Signature Date

Oral & Implant Surgery of Abilene Ryan Q. Green, MD, DDS

Pain Medication Policy

In order to be more efficient in addressing your pain, please be advised that pain medication refills will

be handled ONLY during our business hours.

Business hours: Monday – Thursday 8 a.m. to 4:00 p.m., Friday 8 a.m. to 12:00 p.m. We are closed on

major holidays.

Medication refills will be handled in this manner:

Request your refill by calling your pharmacy. They will fax us the request. Our office fax

number is (325) 232-8943. Please do not leave a voicemail at our office as it will only delay your

refill.

If the refill request is made on a business day, it will typically be refilled that same day.

If you are requesting a refill on a Friday, please make sure you contact your pharmacy before

NOON, as we close early this day.

Medication refill requests over the weekend will be addressed on the NEXT business day.

Medications WILL NOT be replaced if they are lost, stolen out of your car, fell in the toilet/sink,

eaten by pets, left at a relatives, or for any other reasons. If you do not take your medication as

directed and utilize your medication before the refill date, THERE WILL BE NO REFILLS,

REGARDLESS.

Medications must be attained from ONLY ONE (1) pharmacy. Please indicate the name and location

of your pharmacy of choice for office records: ____________________________________________.

If you change pharmacies please contact our office so that we can update your records. This office

verifies patient profiles with area pharmacies. If you are receiving pain medication from another

physician, please inform Dr. Green.

As always, should you have any questions please do not hesitate to call our office at 325-232-8939.

Patient signature: ______________________________________ Date: _____________