Download Medicare Private Contract

Anthony P. Varboncoeur, D.D.S., Inc. Cortland S. Caldemeyer, D.D.S., APC.
Grossmont Oral & Maxillofacial / Facial Plastic Surgery Center
(Mr., Mrs., Ms.) First Name: _________________ Middle Initial: _____ Last Name: _______________________ Sex:  Male  Female
Date of Birth: ______________ Age: ________ Social Security No.: _____________________ Driver’s Lic No.: _____________________
Street Address: _________________________________________________ City: __________________ State: _______ Zip: ___________
Home Tel.: (_______) ________________ Bus. Tel.: (_______) ________________ Ext: ________Cell No.: (_______) _______________ _
Email Address: __________________________________________ Physician:________________________ Phone: (____) _____________
Dentist: _______________________ Phone: (____) _____________ Referred By: __________________Phone: (____) ________________
Have you or anyone in your family ever been in our office before? No _____ Yes _____ Who? __________________________________
Occupation: ________________________________________________________________________________________________________
Student:  Full Time  Part Time  Not School Name/Address: _________________________________________________________
Who will be responsible for your account?
Relation:  Self  Spouse  Mother  Father  Other: ________________________
Name: _______________________ Soc. Sec. #: _______________ Home Tel: (_____)_______________Cell No. (_____)_______________
Street: __________________________________________________ City: ___________________ State: ___________ Zip: ____________
Is this your emergency contact?  Yes  No If no, please list emergency contact here:
Relation: _________________Name: _________________________ Home Tel: (______)____________ Cell No.: (______)_____________
Insurance Information - **VCOMS Does Not Participate in Medicare, Med-i-Cal / Dent-i-Cal, or HMO’s**
Primary Dental Insurance Company:
Name: ____________________________________________________
Insured Information:
Name: _________________________________________________________
Address: __________________________________________________
Relation to Patient:  Self
__________________________________________________________
Sex:  Male  Female
Phone: (______) ____________________________________________
Street: _________________________________________________________
Group No.: _____________Group Name:_______________________
City, State, Zip: _________________________________________________
Local: _________________ Policy No.: _________________________
Phone: (_____) _______________ Soc. Sec. #: _________________________
I.D. #: ____________________________________________________
 Parent  Spouse  Other_____________
Date of Birth: ___________________________
Employer: ______________________________________________________
Secondary Dental Insurance Company:
Insured Information:
Name: ____________________________________________________
Name: _________________________________________________________
Address: __________________________________________________
Relation to Patient:  Self
__________________________________________________________
Sex:  Male  Female
Phone: (______) ____________________________________________
Street: _________________________________________________________
Group No.: _____________Group Name:_______________________
City, State, Zip: _________________________________________________
Local: _________________ Policy No.: _________________________
Phone: (_____) _______________ Soc. Sec. #: _________________________
I.D. #: ____________________________________________________
Employer: ______________________________________________________
Medical Insurance Company:
Name: ____________________________________________________
Insured Information:
Name: _________________________________________________________
Address: __________________________________________________
Relation to Patient:  Self
__________________________________________________________
Sex:  Male  Female
Phone: (______) ____________________________________________
Street: _________________________________________________________
Group No.: _____________Group Name:_______________________
City, State, Zip: _________________________________________________
Local: _________________ Policy No.: _________________________
Phone: (_____) _______________ Soc. Sec. #: _________________________
I.D. #: ____________________________________________________
Employer: ______________________________________________________
 Parent  Spouse  Other_____________
Date of Birth: ___________________________
 Parent  Spouse  Other_____________
Date of Birth: ___________________________
This signature on file is my authorization for the release of information necessary to process my claim. I hereby authorize payment directly to the dentist name of the
insurance benefits otherwise payable to me.
Date: ________________________________ Signature: _______________________________________________________________________________________________
HEALTH / MEDICINE / MEDICATION ALLERGY HISTORY (1)
Patient’s Name
Gender
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 recently had unexplained weight loss, night sweats, fever,
6.
chills, runny nose, watery eyes in conjuction with a rash, severe
coughing spasms more than two weeks, along with chronic fatigue poor
appetite, muscle aches, and swollen salivary glands? Or ever had any
serious illnesses,operations or hospitalizations?...................... Y N
DO YOU HAVE OR HAVE YOU EVER HAD, PLEASE CHECK BOX:
A. □Rheumatic (Scarlet) Fever or □Rheumatic Heart Disease?Y N
B. □Congenital Heart Disease? .............
Y N
C. □ Disease (□Attack,□ Failure, □ Murmur, □Mitral Valve
Prolapse,□Coronary Artery Disease,□Angina,□High Blood
Pressure,□Stroke, □Palpitations, □ STENT
□Surgery, □Pacemaker,□ Valve Replaced or □Damage,
□Abnormal Rhythm,□Pacemaker,□Defibrillater(AICD)? ... Y N
ARE YOU ABLE TO WALK UP 2 FLIGHTS OF STAIRS? Y N
D. Lung Disease (□Asthma, □Emphysema, □COPD,
□Chronic Cough, □Bronchitis, □Pneumonia,
□Tuberculosis, □Shortness of Breath, □Chest Pain,
□Severe Coughing)? ...................................... Y N
E. □Liver Disease, □Jaundice,□Hepatitis, □Bleeding
Disorder, □Anemia(□Sickle Cell),□Bleeding Tendency,
□Blood Transfusion, □Bruise Easily? ............. Y N
F. □Kidney Disease? .......................................... Y N
G. □GI Conditions, □Stomach Ulcers or □Colitis? Y N
H. Genitourinary Conditions? ............................. Y N
I. □Endocrine Conditions, □Diabetes, □Thyroid Disease
□Cold Sores, □Oral Herpes, □Venereal Disease? .. Y N
J. □Neurologic Conditions,□Parkinson’s Dz,□Seizures,
□Convulsions,□Epilepsy,□Fainting or Dizziness? . Y N
K. □Arthritis, □Rheumatism, □Pain in Joints,
□Osteoporosis? .............................................. Y N
L. □Glaucoma or □Eye Surgery?........................Y N
M. Do you have swelling anywhere?................... Y N
N. Implants placed anywhere in your body
(□Hip □ Knee □Organ □ Other )? ............................ Y N
O. □Cancer, □Radiation (X-ray) to the Head & Neck or
□Chemotherapy Treatment for Cancer? ........ Y N
P. □Clicking or popping of jaw joint, □pain near ear,
□difficulty opening mouth, □grind or clench teeth? . Y N
Q. □Sinus or □Nasal problems, □Hay Fever?...... Y N
R. □Leukemia, □HIV / AIDS, or □Any disease, □drug
(steroid) or □transplant , □Operation that has
depressed your immune system? .................. Y N
S. Do you Snore or have sleep apnea?...............Y N
7. ARE YOU USING ANY OF THE FOLLOWING, PLEASE CIRCLE:
A. Antibiotics?..................................................... Y N
B. Anticoagulants (Blood Thinners)? ................. Y N
C. Aspirin, Tylenol or Motrin, Aleve, Ibuprofen(NSAIDS)? ...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 Bisphosphonates for osteoporosis, multiple myeloma or other
cancers (Reclast, Fosamax, Actonel, Boniva,
Aredia, Zometa) ? .........................................Y N
J. Have you ever been advised not to take a
medication?. ...................................................Y N
K. Please complete the medication flow sheet list with
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, PLEASE CIRCLE:
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, Eggs or Soy? .........................Y N
J. Other allergies or reactions? ........................Y N
H. Please list and complete Medicine Allergy Sheet
providing the reaction that you experienced.
9. Do you smoke or chew Tobacco? .........................Y N
How much per day?
10. Is there any past history of a Develpmental Disorder,
Alcohol or Chemical Recreational use, Alzheimer’s 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
12. Have you or an immediate family member had any
problem associated with anesthesia? ...................Y
13. Do you have any other disease, condition or
problem not listed above that you think the doctor
should know about? ..............................................Y
14. Do you wish to talk to the doctor privately
about anything? .....................................................Y
15. Have you ever had a bone density scan? ............Y
16. Do you have an advanced directive Do Not Resuscitate
(DNR) Order?................................................................Y
17. Do you wish to discuss any botox, wrinkle filler, or
facial cosmetic surgical treatments?........................Y
N
N
N
N
N
N
N
18. 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.
HEALTH / MEDICINE / MEDICATION ALLERGY HISTORY (2)
Medicine Allergies with the Reaction,
Allergy □ None
□ See Attached Sheet
Reaction
Prescription Drugs, Diet/Weight Loss Medicines,
***Over the Counter Medicines, Herbal/Holistic Remedies, Vitamins,
Supplements & Minerals
Medication □ None
□ See Attached Sheet
Dosage
Frequency
Prescribing
Doctor
I understand the importance of a truthful and complete Health History to assist my surgeon in providing the best care possible. If I have
not completed the list, I have completed it to the best of my ability, and unable to provide any further unknown information . I also give
my consent for my surgeon to obtain any medical records or laboratory tests deemed pertinent my evaluation and treatment.
Date
Signature of Patient/Guardian Completing Health History
Doctor’s Initials
PLEASE EDIT HEALTH HISTORY IF THERE HAS BEEN ANY CHANGES AND RESIGN, OR RESIGN TO VERIFY THAT THERE HAS BEEN NO
CHANGES IF YOUR HEALTH HISTORY. YOU WILL NEED TO FILL OUT A NEW HEALTH HISTORY IF IT IS GREATER THAN ONE YEAR OLD
Date
Signature of Patient/Guardian Completing Health History
Doctor’s Initials
Date
Signature of Patient/Guardian Completing Health History
Doctor’s Initials
Date
Signature of Patient/Guardian Completing Health History
Doctor’s Initials
Date
Signature of Patient/Guardian Completing Health History
Doctor’s Initials
FINANCIAL AGREEMENT AND AUTHORIZATION FOR TREATMENT
Acknowledgement of Non participation with Medicare, Medi-Cal/Denti-Cal, or HMO’s /
Acknowledgement of TriCare Non-Covered Services /
Acknowledgement of Receipt of HIPAA Privacy Notice /
«lastname», «firstname» «prefix»
ID: «patientid» DOB: «birthday»
Cosmetic fees are guaranteed for 60 days unless $750 non-refundable deposit is applied. Professional services
are rendered to all patients with the understanding that the full amount of the charges are the responsibility of the patient
and/or responsible party. Estimates are good for one year for dental surgery, with the exception of possible changes in
insurance policies and fee schedules unless otherwise. If you have insurance, it is your responsibility to provide us with
all the insurance policy information, both dental and medical. **VCOMS Does Not Participate in Medicare, Med-i-Cal /
Dent-i-Cal, or HMO’s** All copays, deductibles, and noncovered or questionably covered services are to be paid in full at
the time of treatment. If your insurance does not pay within 60 days, you are responsible for paying the entire balance in
full. If insurance payment is then received from the insurance company, we will reimburse you immediately. Each
insurance company is unique because it may provide different coverages and percentages for services, and might also
contain exclusions, limitations, alternate benefits, etc. We make a good faith attempt to estimate your coverage based
upon the resources available by your insurance company. However, the most accurate way to estimate your coverage is
always through a written pre-authorization. As a courtesy, our office will file a pre-authorization per patient preference on
a case by case basis. This may take up to 6 weeks to be processed by your insurance company. It is your responsibility
to follow-up with the office as necessary to review your pre-authorization once it has been processed, discuss any
questions, and to schedule your surgery. However, even insurance verification and pre-authorization is not a guarantee of
payment. If you wish not to or are unable to wait for your pre-authorization, and elect to proceed with your treatment, we
may require that you pay for the service in full, or pay your estimated copay. For our patients without insurance, your
payment is due at the time of treatment. We also offer outside financing for which you may qualify. If you change or
cancel your insurance prior to your treatment or your benefits change or rollover, this estimate may not be accurate. It is
your responsibility to inform us of any changes so we can recheck your benefits. On rare occasions, if you wish to, or it is
deemed medically necessary to have a same day procedure, and you do not wish to, or we are unable to wait until we can fully
verify your insurance, we will collect 50% of our UCR fee. We will then file your insurance for you. Once your insurance has paid,
any over payment will be refunded to you. Any balance will be billed and be due, in full, immediately. Otherwise, our full Usual
and Customary (UCR) fee will be due for any treatment performed. All surgical fees including biopsies do not include the
laboratory cost for the pathological examination of the tissue. Credit can be used in the office for other products or
services. Payments are due at the date of service but can be paid in advance. A 1.5% monthly service charge will be
applied to all patient portion balances after 120 days from the date of service. Claims for advance payments will not be
submitted until the date of service. If you are having a cosmetic procedure done, payment of your surgical fee payment
is due in full at your pre-op visit. If you cancel your surgery after your pre-op visit, there is $750 cancellation fee. Pre
payment for cosmetic products is not refundable.
By signing this contract I understand and agree that I will not submit (or request that my oral and maxillofacial surgeon
submit) a claim to Medicare, Medi-Cal, Denti-Cal, or HMO’s or its agents for services provided by Anthony P. Varboncoeur, DDS, &
Cortland S. Caldemeyer DDS,even if such services would otherwise be covered. I agree to be fully responsible, through insurance
or otherwise, for payment of services rendered by Anthony P. Varboncoeur, DDS, & Cortland S. Caldemeyer DDS, and I
understand that no claims will be submitted to Medicare, Medi-Cal, Denti-Cal, or HMO’s Medicare and no Medicare, Medi-Cal,
Denti-Cal, or HMO’s reimbursement will be provided for these services. I understand that there are no limits specified by Medicare,
Medi-Cal, Denti-Cal, or HMO’s as to the amounts that may be charges by the oral and maxillofacial surgeon for services provided.
I understand that Medi-gap plans do not, and other health and medical care insurance plans may elect not to, make payments for
such services. I understand that I have the right to have services provided by other oral and maxillofacial surgeons, or other
practitioners for whom Medicare, Medi-Cal, Denti-Cal, or HMO’s payment would be made, and that I am not compelled to enter
into private contracts that apply to covered care furnished by other health care professionals who have not opted-out.
I
understand that Anthony P. Varboncoeur, DDS, & Cortland. S. Caldemeyer DDS are not excluded from participation in the
Medicare program under Section 1128 or the Social Security Act or pursuant to any other legal authority.
I acknowledge that these services are not a benefit of my health coverage under TRICARE and that I will not receive the
benefit of the TRICARE Hold Harmless Policy, which otherwise might apply to me. In addition, I acknowledge that if I have obtained
services more frequently than authorized by TRICARE policy, I may be responsible for that professional service. I also understand
that if authorization for this care has been denied by TRICARE, or if reimbursement is denied upon submittal of a claim, I agree that
I will be personally responsible for the payment IN FULL of the billed charges for these services.
I acknowledge that I have been given access to, and reviewed the HIPPA privacy compliance policy of
Grossmont Oral & Maxillofacial / Facial Plastic Surgery Center available in the reception area to my satisfaction. I
understand a copy of the policy is available should I request it.
I understand this notice will serve as acknowledgement of my financial agreement & authorization, nonparticipation with Medicare, Medi-cal, Denti-cal, HMO’s, or Tricare non-covered services, and HIPPA policy for all of my
visits to the Grossmont Oral & Maxillofacial / Facial Plastic Surgery Center.
____________________________________________________________________________________
Patient /Guardian’s
Signature
Date
CONSENT FOR ORAL SURGERY
«lastname», «firstname» «prefix»
ID: «patientid» DOB: «birthday»
Please initial each paragraph after reading. If you have any questions, please ask your doctor BEFORE initialing.
You have the right to be informed about your diagnosis and planned surgery so that you can decide whether to have a procedure
or not after knowing the risks and benefits. Your Planned Treatment is:
_______________________________________________________________________________________________________
_______________________________________________________________________________________________________
Whether a procedure is easy or difficult, it is still a surgical procedure. All surgeries have some risks. They include the following
and others:
_____
______
______
______
______
______
______
______
_____
_____
_____
_____
_____
_____
_____
_____
_____
Swelling, bruising and pain.
Possible infection that might need more treatment.
Changes in the bite or difficulty in opening the mouth because of stress on the jaw joint (TMJ) may happen.
Possible damage to other teeth close to the ones being taken out, (more often those with large fillings or caps), or other
tissues of the face or mouth might be harmed.
It is very rare that the bones of the jaw will break, but it is possible in cases where the teeth are buried very deep in the ir
sockets.
Healing could take longer.
The place where the tooth was taken out could be very painful (dry socket).
I might have a reaction to a medicine.
Sharp ridges or bone splinters may form later at or near where the tooth was taken out. These may need another surgery to
smooth or remove.
The hole where the tooth had been might need more care, or small pieces of the tooth root might be left there to prevent
damage to very important things like nerves or a sinus (a hollow place above your upper back teeth).
Upper back teeth are often close to the sinus and sometimes the tooth or a piece of root can get into the sinus and need
more treatment. An opening may occur from the sinus into the mouth that may need more treatment.
The roots of the lower teeth might be very close to the sensory nerve and after the surgery; there might be pain or a numb
feeling in the chin, lip, cheek, gums, teeth or tongue. It is possible that you might lose your sense of taste. This might last for
weeks or months and can be permanent.
Tissue could be unexpectedly found that is deemed necessary for pathological examination to rule out or adaquetly work up
any pathological process. I give my consent to have the tissue submitted.
I consent to have topical or local anesthesia administered for any procedure where it is deemed necessary.
If I am having a socket graft (bone graft) procedure, I have been informed to my satisfaction of the nature of the
graft material to be used.
I recognize that the office policy of this facility is to not electively treat patients with advanced directive, Do Not Resuscitate
(DNR) orders. If I have such an order, I waive it and agree to be resuscitated for this anesthesia / surgical procedure.
I hereby give permission to take photographs for diagnostic purposes and to enhance the medical record. I agree that these
photographs will remain their property. I further authorize them to use such photographs for practice advertisement, teaching
purposes or to illustrate scientific papers, books, or lectures if, in their judgment medical research, education or science will
be benefited by their use; it is understood that in any such publication or use I shall not be identified by name.
INFORMATION FOR FEMALE PATIENTS
_____
I have told my doctor that I use birth control pills. I have been told that the birth control pills might not work if I take them with
some other medicines (like antibiotics) and I could become pregnant. I agree to talk to my own doctor to start some other
type of birth control while I am being treated, and continue to use the other birth control until that doctor says I can stop it.
CONSENT
I, «lastname», «firstname», understand that my doctor can’t promise that everything will be perfect. I certify that I speak, read and
write English, that I fully understand this consent form for surgery, and that all blanks were filled in prior to my initialing and signing
this form. All my questions have been answered to my satisfaction and I am willing to undergo the proposed surgery.
Patient’s (or Legal Guardian’s) Signature
Date
Patient’s (or Legal Guardian’s) Signature
Date
Wittness Signature
Date
Doctor’s Signature
Date
CONSENT FOR INTRAVENOUS SEDATION OR GENERAL ANESTHESIA
«lastname», «firstname» «prefix»
ID: «patientid» DOB: «birthday»
Please initial each paragraph after reading. If you have any questions about your proposed treatment,
please ask your doctor BEFORE initialing or signing this form. You have the right to be informed about this so
that you can decide whether to have it or not after knowing the risks and benefits. These common procedures are
considered quite safe. Nevertheless, all procedures have some risks. They include the following and others:
_____
_____
______
_____
I give consent to allow my doctor to administer intravenous sedation or general anesthesia, and to all
invasive measures necessary to monitor and care for me during my anesthetic.
that go along with Discomfort, swelling or bruising where the drugs are placed into a vein.
Vein irritation, called phlebitis, where the drugs are placed into a vein. Sometimes this may grow to a level
of discomfort or disability where it may be difficult to move your arm or hand. Sometimes medication or
other treatment may be required.
Nerves travel next to the blood vessels where the drugs are placed into a vein. If the needle hits a nerve
or if drugs or fluid leaks out of the vessel around a nerve, you may have numbness or pain in the nerve
where it runs along the arm. Usually the numbness or pain goes away, but in some cases, it may be
permanent.
Allergic reactions (previously unknown) to any of the medications used.
Nausea and vomiting, although not common, are possible unfortunate side effects. Bed rest, and
sometimes medications, may be required for relief.
Intravenous sedation and general anesthesia are serious medical procedures and, whether given in a
hospital or office, carry the risk of brain damage, stroke, heart attack or death.
If any unforeseen condition should arise during surgery that may call for additional or different procedures
from those planned, I authorize my doctor to use medical judgment to provide the appropriate care.
I recognize that the office policy of this facility is to not electively treat patients with advanced directive, Do
Not Resuscitate (DNR) orders. If I have such an order, I waive the order, and agree to be resuscitated for
this anesthesia / surgical procedure
YOUR OBLIGATIONS:
_
Because anesthetic or sedative medications (including oral premedication) causes drowsiness that lasts
for some time, you MUST be accompanied by a responsible adult to drive you to and from surgery, and
stay with you for several hours until you are recovered sufficiently to care for yourself. Sometimes the
effects of the drugs do not wear off for 24 hours. During recovery time (normally 24 hours), you should not
drive, operate complicated machinery or devices or make important decisions such as signing documents,
etc. On some occasions, especially in older people and with longer cases, it takes longer than expected, weeks to
months, to feel fully recover from the anesthetic effects.
_____
You must have a completely empty stomach. It is vital that you have NOTHING TO EAT OR DRINK for
eight (8) hours prior to your treatment. TO DO OTHERWISE MAY BE LIFE-THREATENING.
Unless instructed otherwise, it is important that you take any regular medications (high blood pressure,
antibiotics, etc.) or any medicines given to you by your surgeon using only a small sip of water.
CONSENT
I, «lastname», «firstname», have read and understand the above paragraphs and realize that Intravenous sedation or
general anesthesia carry have certain serious risks. I request that my choice be used for my treatment. All my
questions have been answered before signing this form. I fully understand the risks involved. I certify that I speak,
read and write English.
Patient’s (or Legal Guardian’s) Signature
Date
Patient’s (or Legal Guardian’s) Signature
Date
Wittness Signature
Date
Doctor’s Signature
Date
IMPORTANT INSTRUCTIONS REGARDING YOUR ANESTHESIA
You will always be given local anesthesia for your surgery, but you may choose any of those listed below as a supplement. Each
choice requires different preparation on your part, and for your safety it is important that you read and follow the instructions
carefully. If you are unclear about anything, please ask your doctor.
For all surgery, please wear comfortable, loose-fitting clothing, and remove all jewelry & contacts lens prior to arriving.
Tops/shirts should have sleeves that are easily drawn up above the elbow. Females should remove nail polish before
surgery, and apply as little makeup as possible.
LOCAL ANESTHESIA will produce a numb feeling in the area being operated on and a feeling of pressure during surgery. You
will be awake and recall the surgery, but there should be no significant discomfort.
1. Have a light meal a few hours prior to surgery.
2. For more extensive procedures you may wish to have someone drive you home.
3. If you prefer to listen to your own music during procedures with local anesthesia, feel free to bring a Ipod etc…
4. Plan to rest for a few hours after surgery.
5. ORAL PREMEDICATION: may be a supplement to local anesthesia and is medication taken by mouth to produce relaxation
before and during your operation.
1.
Take the medication at the time directed before your surgery.
2.
Have a light meal a few hours prior to surgery unless you are also having intravenous or general anesthesia.
3.
It is not safe to drive after taking sedative drugs, and you MUST have someone drive you to and from surgery.
4.
Plan to rest for the remainder of the day. Do not operate power tools, machinery, etc., for 24 hours after surgery.
NITROUS OXIDE is also known as “laughing gas.” You will be relaxed and somewhat less aware of your surroundings, but will
recall most of the surgical event. Nitrous oxide is generally used in conjunction with local anesthesia, but may also be used to
supplement the anesthetic choices below.
1. You may have a light meal four (4) hours prior to surgery.
2. It is best to have someone drive you home.
3. Plan to rest for the remainder of the day.
INTRAVENOUS ANESTHESIA
Both of the anesthetics below include local anesthesia (although general anesthesia does not require its use.)
INTRAVENOUS SEDATION: Medications are given through a vein in your arm or hand, which will cause total relaxation and,
although you will not actually be unconscious, there will be very little recall (if any) of the events surrounding surgery.
1. Do not eat or drink anything (including water) for eight (8) hours prior to surgery. However, it is important that you take any
regular medications (high blood pressure, antibiotics, etc.) or any pre-medication prescription that we have provided, using only a
small sip of water.
2. If you are diabetic, please hold your morning insulin or oral hypoglycemic.
3. For morning appointments, skip breakfast.
4. For afternoon appointments, eat a light breakfast eight (8) hours before your appointment and skip lunch.
5. Take any regular medications with only enough water to get the pill down.
6. You MUST have someone drive you to your appointment, and stay during your procedure until you are discharged. Please do
NOT plan to drop you off for your procedure, and return to pick you up when you are ready to be discharged.
7. Plan to rest for the remainder of the day. Do not operate power tools, machinery, etc., for 24 hours after surgery. On some
occasions, especially in the elderly, it takes longer than expected, weeks, to fully recover from the anesthetic effects.
GENERAL ANESTHESIA: Medications are given through a vein which will result in total loss of consciousness, complete lack of
recall of the event and usually a longer recovery time. General anesthesia has an excellent safety record as an office procedure,
but may, if desired, be provided in a hospital setting. (Your health insurance may not cover you unless there is a bona fide medical
reason for hospitalization.) The same instructions offered above for intravenous sedation apply for general anesthesia.
OTHER SPECIAL INSTRUCTIONS:
Our goal is to provide you with a safe, pleasant and effective anesthetic. In order to do this it is imperative that we have your full
cooperation. Please feel free to ask or call about any questions concerning your surgery or anesthetic. I acknowledge that I have
signed, or been given a copy of the anesthesia consent for review prior to my surgery.
________________________________________________________________________________________________________
Patient’s (or Legal Guardian’s) Signature
Date
POST-OPERATIVE INSTRUCTIONS
***PLEASE READ ALL OF THESE INSTRUCTIONS CAREFULLY*** SOMETIMES THE AFTER-EFFECTS OF ORAL SURGERY ARE QUITE
MINIMAL, SO NOT ALL OF THE INSTRUCTIONS MAY APPLY. COMMON SENSE WILL OFTEN DICTATE WHAT YOU SHOULD DO. HOWEVER,
WHEN IN DOUBT FOLLOW THESE GUIDELINES OR CALL OUR OFFICE FOR CLARIFICATION. OUR NUMBER IS (619) 463-4486.
FIRST HOUR: BITE DOWN GENTLY BUT FIRMLY ON THE GAUZE PACKS THAT HAVE BEEN PLACED OVER THE SURGICAL AREAS, MAKING SURE THEY REMAIN IN
PLACE. DO NOT CHANGE THEM FOR THE FIRST HOUR UNLESS THE BLEEDING IS NOT CONTROLLED. THE PACKS MAY BE GENTLY REMOVED AFTER ONE HOUR. IF
ACTIVE BLEEDING PERSISTS, PLACE ENOUGH NEW GAUZE TO OBTAIN PRESSURE OVER THE SURGICAL SITE FOR ANOTHER 30 MINUTES. THE GAUZE MAY THEN BE
CHANGED AS NECESSARY (TYPICALLY EVERY 30 TO 45 MINUTES). IT IS BEST TO MOISTEN THE GAUZE WITH TAP WATER AND LOOSELY FLUFF FOR MORE
COMFORTABLE POSITIONING.
EXERCISE CARE: Do not disturb the surgical area today. Do NOT rinse vigorously or probe the area with any objects. You may brush your
teeth gently. PLEASE DO NOT SMOKE for at least 48 hours, since this is very detrimental to healing and may cause a dry socket.
OOZING: Intermittent bleeding or oozing overnight is normal. Bleeding may be controlled by placing fresh gauze over the areas and biting on
the gauze for 30-45 minutes at a time.
PERSISTENT BLEEDING: Bleeding should never be severe. If so, it usually means that the packs are being clenched between teeth only and
are not exerting pressure on the surgical areas. Try repositioning the packs. If bleeding persists or becomes heavy you may substitute a tea
bag (soaked in very hot water, squeezed damp-dry and wrapped in a moist gauze) for 20 or 30 minutes. If bleeding remains uncontrolled,
please call our office.
SWELLING: Swelling is often associated with oral surgery. It can be minimized by using a cold pack, ice bag or a bag of frozen peas wrapped
in a towel and applied firmly to the cheek adjacent to the surgical area. This should be applied twenty minutes on and twenty minutes off during
the first 24-72 hours after surgery. If you have been prescribed medicine for the control of swelling, be sure to take it as directed.
PAIN: Unfortunately most oral surgery is accompanied by some degree of discomfort. You will usually have a prescription for pain medication. If you take the first pill before the
anesthetic has worn off, you should be able to manage any discomfort better. Some patients find that stronger pain medicine causes nausea, but if you precede each pain pill with
a small amount of food, chances for nausea will be reduced. The effects of pain medications vary widely among individuals. If you do not achieve adequate relief at first, you may
supplement each pain pill with over the counter analgesics such as aspirin, acetaminophen ( Tylenol), or NSAIDS (Motrin, Advil etc...) as directed on the bottle. Remember that the most
severe pain is usually within six hours after the local anesthetic wears off; after that your need for medicine should lessen. If you find you are taking large amounts of pain medicine
at frequent intervals, please call our office. If you anticipate needing more prescription medication for the weekend, you must call for a refill during weekday business
hours.
NAUSEA: Nausea is not uncommon after surgery. Sometimes pain medications are the cause. Nausea can be reduced by preceding each
pain pill with a small amount of soft food, and taking the pill with a large volume of water. Try to keep taking clear fluids and minimize dosing of
pain medications, but call us if you do not feel better. Classic Coca Cola may help with nausea.
DIET: Eat any nourishing food that can be taken with comfort. Avoid extremely hot foods. Do not use a straw for the first few days after surgery. It is sometimes
advisable, but not absolutely required, to confine the first day’s intake to liquids or pureed foods (soups, puddings, yogurt, milk shakes, etc.) It is best to avoid
foods like nuts, sunflower seeds, popcorn, etc., which may get lodged in the socket areas. Over the next several days you may gradually progress to solid foods.
It is important not to skip meals! If you take nourishment regularly you will feel better, gain strength, have less discomfort and heal faster. If you are a diabetic,
maintain your normal eating habits or follow instructions given by your doctor.
SHARP EDGES: If you feel something hard or sharp edges in the surgical areas, it is likely you are feeling the bony walls which once supported
the extracted teeth. Occasionally small slivers of bone may work themselves out during the following week or so.
MOUTH RINSES: Keeping your mouth clean after surgery is essential. If you wish to use a mouth rinse, salt water rinses consisting of 1/4 teaspoon of salt
dissolved in an 8 ounce glass of warm water two to three times a day is recommended. Alternatively 1/3 water, hydrogen peroxide, and mouthwash can be
substituted.
BRUSHING: Begin your normal oral hygiene routine as soon as possible after surgery. Soreness and swelling may not permit vigorous
brushing, but please make every effort to clean your teeth within the bounds of comfort.
HOT APPLICATIONS: After 72 hours, you may apply warm compresses to the skin over the areas of swelling (hot water bottle, hot moist
towels, heating pad) for 20 minutes on and 20 minutes off to help soothe tender areas . This will also help decrease swelling and stiffness.
HEALING: Normal healing after tooth extraction should be as follows: The first day is usually easier than then second or the third, and it is not
uncommon for the fourth or fifth days to be the most uncomfortable as this is usually when any swelling peaks, or any bruising occurs. By the fifth day
you should be more comfortable and, although possibly still the most swollen, and you can usually begin a more substantial diet. The remainder of the
post-operative course should be gradual, steady improvement, but it does take 7-10 days for the swelling to resolve, and 14-21 days for any
bruising to fade. It also takes 4-6 weeks for dental sockets to completely fill in. If you don’t see continued improvement, please call our office
because it is most likely that you have a dry socket, which is similar to a scab coming off to early, and is best treated by a medicated dressing. If you are
given a plastic irrigating syringe, DO NOT use it for the first five days. Then use it daily according to the instructions until you are certain the tooth socket
has closed completely and that there is no chance of any food particles lodging in the socket.
BONE GRAFT PROCEDURE: It is not uncommon for bone graft procedures to become more uncomfortable after 3-5 days, and then start to feel better in 10-21 days.
The reason for this is that you have essentially gotten a dry socket underneath your graft. Normally a medicated dressing would be placed for a dry socked, but because a
graft has been placed there is no way to place the dressing and oral pain meds are the only option for pain relief. If a Non Resorbable membrane has been placed with the graft,
which is normally the case, it will usually become more visible as the graft heals and will require removal in 4-6 weeks.
SINUS PRECAUTIONS: Because of a very close relationship to the maxillary sinus, many times when a tooth is extracted it may leave a
communication between the mouth and the sinus. We will inform you if this is the case. If you are informed of a sinus communication, it is
important to follow these instructions: Take your prescriptions as directed, refrain from blowing your nose for two weeks, try to stifle all
sneezes, do not use a straw, do not smoke, eat soft foods for several days chewing on the opposite side if possible, do not rinse the
mouth too vigorously for several days. In most cases, small mouth-sinus communications heal uneventfully and cause no problems. We will
check this area carefully at you post-operative visit.
BREAST FEEDING INSTRUCTIONS : You will need to use either breast milk which you have pumped and stored prior to your surgery or a formula
recommended by your pediatrician until 24 hours past you last IV anesthestic or prescribed medication. During this time, you will still need to pump your breasts
and discard the milk in order to maintain proper let down. We recommend discussing your surgery with you pediatrician prior to your appointment in order to have
ay specific questions regarding your infant’s nutritional needs answered.
PLEASE NOTE: Telephone calls for narcotic (pain killer) prescription renewal are ONLY accepted during office hours.
I acknowledge that I have signed, or been given a copy of the surgical consent for review prior to my surgery. It is our
desire that your recovery be as smooth and pleasant as possible. Following these instructions will assist you, but if you have questions about
your progress, please call the office where you had surgery. A 24-hour answering service is available to contact the doctor on call after hours.
Calling during office hours will afford a faster response to your question or concern.
__________________________________________________
Patient’s (or Legal Guardian’s) Signature
Date
___________________________________________________
Patient’s (or Legal Guardian’s) Signature
Date
Your Surgery has been Scheduled For:
Date: ___________ Check In: __________
Your Post-Operative Visit has been Scheduled For:
Date: ___________ Check In: ________________