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HEALTH HISTORY
Patient’s Name
Date of Birth
__________________
_______________
Primary Care Physician
Dentist
Height
Today’s Date
Weight
___________________
Orthodontist
ALL RESPONSES ARE KEPT CONFIDENTIAL
Answer all questions by circling Yes (Y) or No (N)
o
o
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
Last ER visit or Hospital Admission? _______________
E.
F.
G.
H.
I.
J.
K.
L.
M.
N.
O.
P.
Q.
R.
S.
o
o
Are you taking or have you ever taken
Bisphosphonates (or monoclonal antibodies) for
osteoporosis, multiple myeloma or other cancers
(Reclast, Fosamax, Actonel, Boniva, Aredia,
Zometa, Prolia, Xgeva, Denosumab) ? ............ Y N
Do you play any sports or exercise? ............................Y N
Do you have any shortness of breath with activity? ......Y N
If yes, how many city blocks can you walk?______________
Date of last physical exam ....................................................
Are you now under a physician’s care for
a particular problem? .....................................................Y N
Please Describe:__________________________________
Have you ever had any serious illnesses,
operations or hospitalizations? If so, describe:..............Y N
Seizures, Convulsions, Epilepsy ............................ Y
Bleeding Disorder, Anemia, Bleeding Tendency,
Blood Transfusion? Do you bruise easily? .............Y
Liver Disease (Jaundice, Hepatitis)? .......................Y
Kidney Disease? .....................................................Y
Diabetes? ................................................................Y
Thyroid Disease (Goiter)? .......................................Y
Arthritis? ..................................................................Y
Stomach Ulcers or Colitis? ......................................Y
Glaucoma?..............................................................Y
Osteoporosis? .........................................................Y
Implants placed anywhere in your body
(Heart Valve, Pacemaker, Hip, Knee)? ...................Y
Radiation (X-ray) treatment for Cancer? .................Y
Clicking or popping of jaw joint (TMJ), pain,
difficulty opening mouth, grind or clench teeth? ......Y
Sinus or Nasal problems? .......................................Y
Any disease, drug or transplant operation
that has depressed your immune system? .............Y
J.
K.
o
N
N
N
N
N
N
N
N
N
N
N
N
N
N
N
ARE YOU USING ANY OF THE FOLLOWING:
A. Antibiotics?..............................................................Y N
B. Anticoagulants (Blood Thinners)? ...........................Y N
C. High Blood Pressure medications? .........................Y N
D. Steroids (Cortisone, Prednisone, etc.)? ..................Y N
E. Insulin or Oral Diabetic drugs?................................Y N
Past Surgical History:
________________________________________________
Any personal or family history of surgical complication?
Malignant hyperthermia Y N
Nausea / Vomiting
Y N
Prolonged bleeding
Y N
o
Have you ever been advised not to take a medication?
................................................................................ Y N
Please list all medications, & DOSES for prescription
medications, over-the-counter medications, herbs,
vitamins:_____________
_____________________
____________________
_____________________
____________________
_____________________
____________________
_____________________
____________________
_____________________
____________________
_____________________
____________________
_____________________
ARE YOU ALLERGIC TO OR HAVE YOU HAD AN
ADVERSE REACTION TO:
A. Local Anesthesia (Novocain, etc.)? ........................ Y
B. Penicillin............................................................... Y
Other antibiotics:
C. Aspirin or Ibuprofen?............................................... Y
D. Codeine or other pain killers? ................................. Y
E. Latex ....................................................................... Y
F. Lecithin ................................................................. Y
H. Other allergies or reactions? Please list................. Y
N
N
N
N
N
Tobacco Use
Y
N Date quit:____________
Smokeless tobacco Y
N Date quit:____________
Alcohol Use
Y
N Date quit:____________
THC/Marijuana
Y
N Date quit:____________
Other Drug Use
Y
N Date quit:____________
Have you had any serious problems associated with
any previous dental treatment? ...................................... Y N
Do you have any other disease, condition or
problem not listed above that you think the doctor
should know about? ....................................................... Y N
Do you wish to talk to the doctor privately
about anything? ............................................................. Y N
Have you ever had a bone density scan? ..................... Y N
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. When was your last menstrual cycle?_______________
D. 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 dentist in providing the best care possible. I
have had the opportunity to discuss my Health History with my dentist.
X
Date
N
N
Signature of Person Completing Health History
Doctor’s Initials
HEALTH HISTORY
Patient’s Name
Date of Birth
Date
Chief Dental Complaint: ________________________________________________________________________________________
____________________________________________________________________________________________________________
Are you under the care of a physician?
Primary Care Physician__________________________________________
Cardiologist___________________________________________________
Rheumatologist _______________________________________________
Other _______________________________________________________
phone/fax #_____________________________________
phone/fax #_____________________________________
phone/fax #_____________________________________
phone/fax #_____________________________________
I have read and understand the above. Any questions I had about this form have been answered and I understand the answers. I
understand it is my responsibility to fill out the form correctly and completely.
Date: _____________ Patient’s (or Guardian’s)
Signature: X _______________________________________
FOR COMPLETION BY THE DOCTOR
Significant findings from patient interview concerning medical history:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Dental Management Considerations:
_____________________________________________________________________________________________________________
_____________________________________________________________________________________________________________
Consultations to obtain:
_____________________________________________________________________________________________________________
Date: __________________
3/14
Doctor’s Signature: _______________________________________
Leavenworth Oral and Maxillofacial surgery
Financial Policy
Thank you for choosing Leavenworth Oral and Maxillofacial Surgery as your oral surgery provider. Our primary
mission is to deliver the best and most comprehensive care available. An important part of the mission is making
the cost of optimal care as easy and as manageable for our patients as possible by offering several payment options,
which are listed below.
Payment Options:
1.
Cash
2.
Check
3.
Visa®, MasterCard®, Discover Card®, or American Express®
4.
Convenient Monthly Payment Options¹ from CareCredit Healthcare Credit Card
- Allows you to pay over a period of time
- No annual fees or pre-payment penalties
Leavenworth Oral and Maxillofacial Surgery requires payment at the beginning of your treatment. If you choose to
discontinue care before treatment is complete, you will receive a refund less the cost of care received.
For plans requiring multiple appointments, alternative payment arrangements may be provided.
Services rendered are fully the financial responsibility of the patient or account guarantor. As a courtesy, we will
work with your insurance carrier (if applicable) to maximize your benefit for treatment reimbursement.² Any
outstanding balance on the account is the patient’s responsibility. Should the insurance company send payment to
the policy holder, payment must be forwarded to our clinic within 48 hours.
A fee of $50 is charged for patients who miss or cancel surgery appointments without 48-hour notice.
Leavenworth Oral and Maxillofacial Surgery charges $60 for returned checks.
Upon failure to provide payment for rendered service, three attempts will be made by our clinic to request
payment. If no payment is received after the third attempt, the patient’s account will be submitted to the collections
process; any cost incurred by our clinic to retrieve the overdue balance will be the patient’s responsibility.
Any violation of this agreement will, at the provider’s election, terminate patient charge privileges with provider
and bring any balance owed by patient to provider immediately due and payable.
If you have any questions, please do not hesitate to ask. We are here to help you get the dentistry you want or need.
Patient, Parent or Guardian Signature _____________________________Date____________
Patient Name (Please Print)__________________________________________________
¹Subject to credit approval
²However, if we do not receive payment from your insurance carrier within 60 days, you will be responsible for
payment of your treatment fees and collection of your benefits directly from your insurance carrier.
First Name:___________________________ M.I.______ Last Name:_________________________________
Dentist: ____________________ Physician: ____________________ Referral Source:___________________
Date of Birth:____________________ Sex: □Male □Female Social Security #:________-______-________
Address:____________________________ City:_____________________ State:_______ Zip Code:________
Primary Phone:________________ (home/work/cell) Secondary Phone:_________________ (home/work/cell)
Email Address:_________________¬¬¬___________ Marital Status: □Married □Single □Divorced □Separated
Student: □Full Time □Part Time □Not a Student Name of School:___________________________________
Employed: □Full Time □Part Time □Not Employed Name of Employer:______________________________
EMERGENCY CONTACT: ______________________ Relationship:_____________ Phone:______________
Who will be financially responsible for your account? (If self, continue to next section)
□Self □Mom □Dad □Spouse □Other Name: ¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬¬______________________Date of
Birth:__________________
Address:____________________________ City:_____________________ State:_______ Zip Code:________
Primary Phone:________________ (home/work/cell) Secondary Phone:_________________ (home/work/cell)
Email Address:_________________¬¬¬___________ Marital Status: □Married □Single □Divorced □Separated
Employed: □Full Time □Part Time □Not Employed Name of Employer:______________________________
Dental Insurance Information:
Name of Insured Policyholder:______________________________ Relationship to Patient:________________
Policyholder Date of Birth:____________________ Social Security #:________-______-________
Name of Dental Insurance Carrier:__________________________ Dental Insurance Phone:________________
Dental Insurance Address:_____________________________ City:_____________________ State:_________
Insured ID:_________________________ Group #___________________ Group Name:__________________
Medical Insurance Information: If this information is the same as the Dental Insurance, leave this portion blank.
Name of Insured Policyholder:______________________________ Relationship to Patient:________________
Policyholder Date of Birth:____________________ Social Security #:________-______-________
Name of Medical Insurance Carrier:_________________________ Medical Insurance Phone:______________
Medical Insurance Address:_____________________________ City:_____________________ State:________
Insured ID:_________________________ Group #___________________ Group Name:__________________
Leavenworth Oral & Maxillofacial Surgery
Card Oral & Maxillofacial Surgery Inc.
Patient Payment Agreement
Thank you for giving Leavenworth Oral and Maxillofacial Surgery the opportunity to serve as your oral surgery
provider. We are excited to move forward in helping you obtain your oral health goals, and have created a
treatment proposal personalized to your needs.
Patient Name:__________________________________________________________________
Guarantor Name:______________________________________________________________
The estimated cost for your personalized treatment plan is $_____________________________.
The estimated patient portion due day of surgery is $___________________________________.
Once treatment has begun, changes in the anticipated treatment proposal may be required, depending on health
conditions encountered. We will inform you if any changes in proposed treatment occur and you will be given the
option of continuing or changing treatment. ________(initial)
As stated in Leavenworth Oral and Maxillofacial Surgery’s financial policy, the payment for the estimated patient
portion is required, in full, by the surgery date. If you choose to discontinue care before treatment is complete, you
will receive a refund less the cost of care received.
It is ESTIMATED that you insurance will cover $______________. The amount covered by your specific
insurance policy is an estimate, and not a guarantee of payment. Any discrepancies in the estimated amount and
actual payment received will be the patient’s responsibility. Any questions regarding your insurance benefits or
payments may be taken up with your insurance company._______(initial)
Your signature below forms a binding agreement between Leavenworth Oral and Maxillofacial Surgery (LOMS –
the provider of medical services) and the patient who is receiving medical services, or the responsible party.
Patient, Parent or Guardian Signature
Patient Name (Please Print)
Date
(HIPAA) Notice of Privacy Practices for Protected Health Information (PHI)
This notice describes how medical information about you may be
used and disclosed and how you can get access to this information.
Please review it carefully!
With your consent, the practice is permitted by federal privacy laws to make uses and disclosures of your health information
for purposes of treatment, payment, and health care operations. Protected health information (PHI) is the information we
create and obtain in providing our services to you. Such information may include documenting your symptoms, examination
and test results, diagnoses, treatment, and applying for future care or treatment. It also includes billing documents for those
services.
Example of uses of your health information for treatment purposes:
A nurse obtains treatment information about you and records it in a health record. During the course of your treatment, the
doctor determines a need to consult with another specialist in the area. The doctor will share the information with such
specialist and obtain input.
Example of use of your health information for payment purposes:
We submit a request for payment to your health insurance company. The health insurance company requests information
from us regarding medical care given. We will provide information to them about you and the care given.
Example of Use of Your Information for Health Care Operations:
We obtain services from our insurers or other business associates such as quality assessment, quality improvement,
outcome evaluation, protocol and clinical guidelines development, training programs, credentialing, medical review, legal
services, and insurance. We will share information about you with such insurers or other business associates as necessary to
obtain these services.
Your Health Information Rights
The health record we maintain and billing records are the physical property of the practice. The information in it, however,
belongs to you. You have a right to:

Ask someone who has medical power of attorney or your legal guardian, to exercise your rights and make choices about
your health information.

Request a restriction on certain uses and disclosures of your health information by delivering the request in writing to our
office. We are not required to grant the request but we will comply with any request granted;
Request a restriction on disclosures of medical information to a health plan for purposes of carrying out payment or
health care operations; and the PHI pertains solely to a health care service for which the provider has been paid out of
pocket in full—we must comply with this request;
Request you be allowed to inspect your health record and billing record - you may exercise this right by delivering the
request in writing to our office;
Obtain a copy of your paper or electronic record.
Appeal a denial of access to your protected health information except in certain circumstances;
Request that your health care record be amended to correct incomplete or incorrect information by delivering a written
request to our office;
File a statement of disagreement if your amendment is denied, and require that the request for amendment and any
denial be attached in all future disclosures of your protected health information;
Obtain an accounting of disclosures of your health information as required to be maintained by law by delivering a written
request to our office. An accounting will not include internal uses of information for treatment, payment, or operations,
disclosures made to you or made at your request, or disclosures made to family members or friends in the course of
providing care;
Request that communication of your health information be made by alternative means or at an alternative location by
delivering the request in writing to our office; and,
Elect to opt out of receiving further communications to raise funds for the practice.
Revoke authorizations that you made previously to use or disclose information except to the extent information or action
has already been taken by delivering a written revocation to our office.
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If you want to exercise any of the above rights, please contact [insert name of designated staff member, phone number,
or address], in person or in writing, during normal hours. S[he] will provide you with assistance on the steps to take to
exercise your rights.
Our Responsibilities
The practice is required to:
 Maintain the privacy of your health information as required by law;
 Provide you with a notice of our duties and privacy practices as to the information we collect and maintain about you;
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Abide by the terms of this Notice;
Notify you if we cannot accommodate a requested restriction or request;
Accommodate your reasonable requests regarding methods to communicate health information with you;
We will never share your information (for marketing purposes, sale of your information, sharing of psychotherapy notes)
without your written permission:, and
Notify you if you are affected by a breach of unsecured PHI
We reserve the right to amend, change, or eliminate provisions in our privacy practices and access practices and to enact
new provisions regarding the protected health information we maintain. If our information practices change, we will amend
our Notice. You are entitled to receive a revised copy of the Notice by calling and requesting a copy of our "Notice" or by
visiting our office and picking up a copy.
To Request Information or File a Complaint
If you have questions, would like additional information, or want to report a problem regarding the handling of your
information, you may contact our office at 913-772-4334. Additionally, if you believe your privacy rights have been violated,
you may file a written complaint at our office by delivering the written complaint to our office manager. You may also file a
complaint by mailing it or e-mailing it to the Secretary of Health and Human Services
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We cannot, and will not, require you to waive the right to file a complaint with the Secretary of Health and Human
Services (HHS) as a condition of receiving treatment from the practice.
We cannot, and will not, retaliate against you for filing a complaint with the Secretary.
Other Disclosures and Uses
Notification
Unless you object, we may use or disclose your protected health information to notify, or assist in notifying, a family member,
personal representative, or other person responsible for your care, about your location, and about your general condition, or
your death.
Communication with Family
Using our best judgment, we may disclose to a family member, other relative, close personal friend, or any other person you
identify, health information relevant to that person's involvement in your care or in payment for such care if you do not object
or in an emergency.
Food and Drug Administration (FDA)
We may disclose to the FDA your protected health information relating to adverse events with respect to products and
product defects, or post-marketing surveillance information to enable product recalls, repairs, or replacements.
Workers Compensation
If you are seeking compensation through Workers Compensation, we may disclose your protected health information to the
extent necessary to comply with laws relating to Workers Compensation.
Public Health
As required by law, we may disclose your protected health information to public health or legal authorities charged with
preventing or controlling disease, injury, or disability.
Abuse & Neglect
We may disclose your protected health information to public authorities as allowed by law to report abuse or neglect.
Correctional Institutions
If you are an inmate of a correctional institution, we may disclose to the institution, or its agents, your protected health
information necessary for your health and the health and safety of other individuals.
Law Enforcement
We may disclose your protected health information for law enforcement purposes as required by law, such as when required
by a court order, or in cases involving felony prosecutions, or to the extent an individual is in the custody of law enforcement.
Health Oversight
Federal law allows us to release your protected health information to appropriate health oversight agencies or for health
oversight activities.
Judicial/Administrative Proceedings
We may disclose your protected health information in the course of any judicial or administrative proceeding as allowed or
required by law, with your consent, or as directed by a proper court order.
Research
We may disclose information to researchers when their research has been approved by an institutional review board that has
reviewed the research proposal and established protocols to ensure the privacy of your protected health information.
Marketing
We may contact you to provide you with information about treatment alternatives, or with information about other healthrelated benefits and services that may be of interest to you.
For Specialized Governmental Functions
We may disclose your protected health information for specialized government functions as authorized by law, such as to
Armed Forces personnel, for national security purposes, or to public assistance program personnel.
Other Uses
Other uses and disclosures besides those identified in this Notice will be made only as otherwise authorized by law or with
your written authorization and you may revoke the authorization as previously provided.
1. May we have your permission to leave voice and/or text messages regarding appointments or requests for your call
backs? Yes___No___Cell phone/answering machine ( )____________
2. To whom may we release protected health information (PHI)?
____ To myself only
____ To myself and PCP Dr. ______________________
____ To myself and the following designated person(s)
Name_________________________ Relationship____________________
Name_________________________ Relationship____________________
Name_________________________ Relationship____________________
Assignment of Insurance Benefits Release of Medical Information
I understand pre-certifications/authorizations/referrals are my responsibility. I hereby consent to medical evaluations, testing, and/or
treatment provided to me by (Leavenworth) Card Oral & Maxillofacial Surgery Inc. I understand that in order to carry out treatment,
payment and other healthcare operations, Card Oral & Maxillofacial Surgery Inc. may use PHI. I authorize release of any information
concerning me or my child’s health care, advice and treatment provided for the purpose of evaluating and administering claims for
insurance benefits. I also hereby give lifetime authorization for payment of insurance benefits directly to Card Oral & Maxillofacial Surgery
Inc. and agree to any remaining balance once my insurance plan has processed my claim. I understand that I am financially re sponsible
for all charges whether or not they are covered by insurance. In the event of default, I agree to pay all costs of collections and reasonable
attorney fees.
I hereby acknowledge that I have received a copy of this practice’s Notice of Privacy Practices. I have been given the opportunity to ask
any questions I may have regarding this Notice.
X_________________________________
Name
8/14
______________Card Oral & Maxillofacial Surgery Inc.
Date
3550 S 4th St Suite 240
Leavenworth, KS 66048
913.772.4334