NEW PATIENT REGISTRATION (Please complete entire form) Patient s full name: Age: Soc. Sec. # Referred By: Reason for Visit:

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1 Page 1 of 5 Dr. Patient Care Coordinator: Clinical Assistant: Today s Date NEW PATIENT REGISTRATION (Please complete entire form) Patient s full name: Age: Soc. Sec. # Referred By: Reason for Visit: HEALTH HISTORY YES NO 1- Are you allergic to any food or drugs? Allergies? If yes, please explain: 2- Are you taking any drugs or medicine? If yes, please explain: 3- Have you ever been hospitalized? If yes, please explain: 4- Have you ever been seriously ill? 5- Have you ever had cobalt or radiation therapy other than x-rays? 6- Have you ever taken cortisone or similar drugs? 7- Have you ever bled excessively from minor cuts, previous surgery, or following a tooth extraction? 8- Does anyone in your family have a history of bleeding problems, diabetes, problems involving general anesthesia? 9- Women- Are you pregnant? 10- Do you wear contact lenses? If so, please remove prior to surgery. Have you had or do you now have any of the following? YES YES YES Asthma Heart Surgery Cirrhosis Hay Fever Heart Attack Any Blood Disease Sinusitis Heart Failure Arthritis Nasal Obstruction Heart Murmur Stomach ulcers Bronchitis Stroke Any Kidney Disease Emphysema Chest Pain Bladder Problem Tuberculosis Angina Thyroid Gland Problems Lung Problems Heart Problems HIV (AIDS) Epilepsy Glaucoma Moniliasis (Yeast Infection) Convulsions Any Eye Disease Thrush Rheumatic Fever Hepatitis Cold Sores High Blood Pressure Yellow Jaundice Herpes Infection Joint Replacement Diabetes TMJ Disorders Herbal Medications Diet Pills Bisphosphonates (Fosamax, Boniva) Smoker Liver Disease Solace Staff Notes: To the best of my knowledge, the answers that I have given to the above questions are correct. (If patient is less than 18 years of age, the signature of the patient s legal guardian is required.)

2 Page 2 of 5 Jaime A. Romero, Jr., D.D.S. Section I: Patient Information Date Name Nickname: Driver s License # Address: City: State: Zip: Employer: Home # ( ) Cell # ( ) Work # ( ) DOB: SSN# Check Appropriate Box: Male Female Check Appropriate Box: Single Married Widowed Separated Divorced If Student, Name of School City/State FT PT Referring Dentist General Dentist *Emergency Contact Name *Emergency Contact Phone # Relative seen here before (Name) May we leave a voic message on your phone? Yes No Section II *If the patient is the responsible party, please select Self and do not fill out information again* *The responsible party must be 18 years of age or older* *The responsible party must be present* Responsible Party Relationship to Patient: Self Spouse Parent Other Name: DOB: SSN# Address: City: State: Zip: Employer: Home # ( ) Cell # ( ) Work # ( ) Section III Insurance Information Dental Insurance Subscriber s Name DOB Relationship to Patient SSN#: Name of Employer: Insurance Company Grp # ID# Ins Co Address: Medical Insurance Subscriber s Name DOB Relationship to Patient SSN#: Name of Employer: Insurance Company Grp # ID# Ins Co Address:

3 Page 3 of 5 SOLACE ORAL SURGERY, PC Jaime A. Romero Jr., D.D.S rd Ave. North Nashville, TN (615) NOTICE OF PRIVACY PRACTICES FOR PROTECTED HEALTH INFORMATION Our Pledge Regarding Your Medical Information Solace Oral Surgery (SOS) is committed to protecting medical information about you. We create a record of the care and services you receive at SOS for use in your care and treatment. This Notice tells you about the ways in which we may use and disclose medical information about you. It also describes your rights and certain obligations we have regarding the use and disclosure of your medical information. We are required by law to: Make sure that your medical information is protected Give you this Notice describing our legal duties and privacy practices with respect to medical information about you; and Follow the terms of the Notice that is currently in effect I authorize the following individuals to receive information about my appointments, treatment and/or account: (If you do not have anyone you authorize to receive information about your appointments, do not fill out this section and SIGN BELOW) Print name Relationship Date of birth Phone# Print name Relationship Date of birth Phone# By signing below, you state that you have been notified and understand this policy. ***If you would like a full copy of the Notice of Privacy Practices, please ask someone at the front desk***

4 Page 4 of 5 CANCELLATION POLICY Dr. Romero is dedicated to your health. When you miss an appointment, other patients are unable to take your place and are delayed. If you are unable to keep an appointment, we ask that you cancel at least 24 hours in advance. Please call as soon as possible so that another patient can be given your appointment. A no show or late cancellation is defined as missing or rescheduling an appointment without giving 24 hours of advanced notice. There will be a $75.00 charge for a missed appointment or an appointment that was cancelled late. Insurance will NOT cover charges for no show or late cancellation fees. This charge is in addition to any other charges you may have incurred. Repeated missed appointments may result in discharging the patient from the practice. Solace Oral Surgery understands that emergencies will occur and consideration will be made for missed or no show appointment. By signing below, you state that you have been notified and understand this policy. Patient s or Guardians Signature Date

5 Page 5 of 5 OFFICE POLICIES PLEASE READ CAREFULLY AND SIGN BELOW: 1. Payments for surgery are due on the same day of service, prior to the procedure. 2. You agree to let Solace Oral Surgery take a photo of the patient for the patient s file, even after providing identification. 3. Your insurance company does not guarantee payment until a claim is received, reviewed, and processed. 4. Your insurance policy is a contract between you, your employer and the insurance company. Some services are not covered in every contract. Insurance companies select certain services that they will cover and those that they will not. Please check your plan for coverage prior to your appointment. Many insurance plans require you to go to a preferred provider. It is the patient s responsibility to check with your insurance company for coverage. 5. We are participating in the following insurance plans (Some subject to change): a. Blue Cross preferred dental plan b. Blue Cross medical network P & S c. Delta Dental preferred and PPO, AARP, & Healthsprings d. Guardian PPO dental e. MetLife PPO dental f. Cigna medical/ppo dental & DHMO dental g. Aetna PPO dental h. Tenncare- Amerigroup, Bcbs coverkids i. Dentaquest Tenncare & Marketplace plan j. United Concordia PPO dental k. Dentemax l. United Healthcare dental m. Humana medical/ppo dental plans n. United Healthcare PPO dental only o. Ameritas PPO dental p. Assurant PPO dental 6. Collections: It is understood that you, the patient or guarantor are responsible for the entire cost of treatment received. If your financial obligation is not met, then the following additional charges will be assessed to your account accordingly: All accounts over 90 days will be sent to the collection agency unless payment arrangements have been made and adhered to. Collection fees, attorney fees and court costs as allowed by the State of Tennessee law will be the responsibility of the accountholder. 7. Return check fee of $30.00, plus payment of balance by cash or debit card. 8. Please inform the receptionist if you would like a pre-determination filed with your insurance company. Please understand that it usually takes 4 6 weeks to receive a response from your insurance company. When a response is received, you will be notified. Please be aware that a pre-determination is not a guarantee of benefits. 9. We are NOT in network with Medicare, therefore we do not file claims with them. With that being said, if you have a Medicare supplement we do not file claims with the supplemental policy because claims have to first be paid by Medicare (we are not in network with), and then would be paid by the Medicare supplemental policy. You must go to a Medicare provider to be covered, they do not provide any out of network coverage.