Patient Registration

Please complete the history form prior to your appointment with WOOD & MYERS OMS. Patients under the age of 18 or those who have a power of attorney should have it completed by the person legally responsible. That person will also need to accompany the patient to the appoinment. All responses are kept confidential.

If you wish to download a printable form to take into the office at the time of your appointment, please CLICK HERE TO DOWNLOAD

Patient Information

Patient Last Name

Patient First Name

Middle Name

DOB

Soc Sec #

Gender

Marital_Status

Student Status

Name of School

Employment Status

Employer

Are you a returning patient?
Yes No

Referred By

Digital Copy of your Drivers License

Patient Contact Information

Street Address

City

State

Zip Code

Home Phone

Cell Phone

Emergency Contact

Last Name

First Name

Phone Number

Relationship to Patient

Trusted Person for Release of Information

When required, I permit Wood & Myers OMS to provide all my information regarding medical & dental treatment including financials to:

Last Name

First Name

Phone Number

Relationship to Patient

Healthcare Providers

General Dentist

General Dentist Address / Phone

Primary Care Doctor

Primary Care Doctor Address / Phone

Specialist

Specialist Address / Phone

Pharmacy

Pharmacy Address / Phone

Laboratory

Laboratory Address / Phone

Insurance Coverages

Primary Dental Insurance

If you have a digital copy of your insurance card, please use this box to upload your card and bypass manual entry. PLEASE INCLUDE FRONT AND BACK OF CARD.

Front of Card: Back of Card:

Insurance Provider

Company Name

Company Phone Number

Policy or ID #

Group #

Policy Holder / Subscriber

Name

Employer

Primary Medical Insurance

If you have a digital copy of your insurance card, please use this box to upload your card and bypass manual entry. PLEASE INCLUDE FRONT AND BACK OF CARD.

Front of Card: Back of Card:

Insurance Provider

Company Name

Company Phone Number

Policy or ID #

Group #

Policy Holder / Subscriber

Name

Employer

Patient's Medical History

Your medical history is important to the treatment you will receive. It is extremely important that you respond to each question honestly and completely.

Height

Weight

Cardiovascular System
Are You Currently Under the Care of a Cardiologist?	Yes	No
If Yes, Cardiology Practice:
Mitral Valve Prolapse	Yes	No
Chest Pain, Angina	Yes	No
Heart Attack or Stroke	Yes	No
Heart Palpitations or Flutter	Yes	No
High Blood Pressure	Yes	No
Rheumatic Fever	Yes	No
Other Heart or Vessel Disease	Yes	No
If Yes, Please Describe:

Pulmonary System
Asthma	Yes	No
Bronchitis (Past 3 Months)	Yes	No
Chronic Obstructive Lung Disease	Yes	No
Emphysema	Yes	No
Shortness of Breath	Yes	No
Sleep Apnea	Yes	No
Pneumonia (Past 3 Months)	Yes	No
Productive Cough	Yes	No
Nasal Congestion	Yes	No
Nose Bleeds	Yes	No
Smoking / Tobacco Products	Yes	No
If Yes, for How Long:

Women
Are You Pregnant or Planning Pregnancy?	Yes	No
Are You Nursing?	Yes	No

Gastrointestinal
Gastroesophageal Reflux Disease	Yes	No
Colitis	Yes	No
Crohn's Disease	Yes	No
Irritable Bowel Syndrome	Yes	No
Other	Yes	No
If Yes, Please Describe:

Other
Anemia	Yes	No
Jaundice	Yes	No
Hepatitis	Yes	No
Mononucleosis (Mono)	Yes	No
Diabetes	Yes	No
Thyroid Disease	Yes	No
Epilepsy / Convulsions	Yes	No
Glaucoma	Yes	No
Fainting Episodes	Yes	No
Bleeding Problems	Yes	No
Venereal or AIDS Diagnosis	Yes	No
Blood Transfusion	Yes	No
Tuberculosis	Yes	No
Emotional / Mental Health Problems	Yes	No
Motion Sickness	Yes	No
Kidney Disease	Yes	No
Sickle Cell Disease	Yes	No
Muscular Disease	Yes	No
Parkinson's Disease	Yes	No
Wear Contact Lenses / Glasses	Yes	No
TMJ	Yes	No
Surgical Joint Replacements	Yes	No
Osteoporosis / Osteopenia	Yes	No
Have you had a concussion in the past year?	Yes	No
If Yes, Date and Medical Issues/Restrictions:
Are you presently under a doctor's care for any reason?	Yes	No
If Yes, Please Describe:
Have you or a blood relative had serious complications with general anesthesia?	Yes	No
If Yes, Please Describe:
Have you had a problem with local anesthesia?	Yes	No
If Yes, Please Describe:
Is there anything loose or removeable in your mouth i.e. loose tooth, dentures, retainers, tongue jewelry, etc?	Yes	No
Do you use Alcohol?	Yes	No
If Yes, How Much:
Have you had radiation treatments?	Yes	No
If Yes, Please Describe Date, Area and Amount of Radiation:
Do you have any disease, drugs or transplant operation that has depressed your immune system?	Yes	No
Are you taking, or have you ever taken, bone density meds or bisphosphonates such as Fosamax, Boniva, Actonel, IV-Zometa, Aredia, Xgeva, Prolia, or Reclast in the past 12 years?	Yes	No
Has a physician or previous dentist recommended that you take antibiotics prior to your dental treatment?	Yes	No
If Yes, for What Reason:
Is there any other condition not listed on this form that you feel we should be made aware of?	Yes	No
If Yes, Please Describe:

Allergies
Are you allergic to Latex or rubber products?	Yes	No
Are you allergic to Soy products or eggs?	Yes	No
Are you allergic to local anesthetic or numbing meds?	Yes	No
Are you allergic to any medications?	Yes	No
If Yes, Please List:

Please list any specific medications indicated above and/or any other medications not listed above that you are currently taking including prescription medications, diet drugs, over the counter medications, herbal or holistic remedies, vitamins, or minerals.

** Use the "Add Rows" option to add more spots.

Name of Medication

Dosage

Condition

NOTE: If you are using oral contraceptives it is important that you understand that antibiotics and other medications may interfere with the effectiveness of oral contraceptives. Please consult your physician for further guidance.

List any previous surgeries or serious illnesses.

By entering your name in the signature box provided below, you are verifying that the statements and information provided are true and correct and are attesting to the validity of all contents within this electronic submission and are deemed to have electronically signed this form.

Wood & Myers OMS

I understand the importance of a truthful and complete health history to assist my doctor in providing the best care possible. To the best of my knowledge, the above information is complete and correct.

Signature of Patient, Parent, Guardian (1)

FINANCIAL POLICY

WE ARE COMMITTED TO PROVIDING YOU WITH THE BEST POSSIBLE CARE AND WOULD BE HAPPY TO DISCUSS OUR PROFESSIONAL FEES WITH YOU AT ANY TIME. A CLEAR UNDERSTANDING OF OUR FINANCIAL POLICY IS IMPORTANT TO OUR PROFESSIONAL RELATIONSHIP. PLEASE ASK IF YOU HAVE ANY QUESTIONS ABOUT OUR FEES, FINANCIAL POLICY, OR YOUR FINANCIAL RESPONSIBILITY. IF YOU HAVE OR DO NOT HAVE MEDICAL AND/OR DENTAL INSURANCE, WE EXPECT PAYMENT IN FULL FOR ALL TREATMENT AT THE TIME OF SERVICE. WE ACCEPT CASH, CHECKS, VISA, MASTERCARD, AMERICAN EXPRESS, DISCOVER AND CARE CREDIT.

WE MAKE EVERY EFFORT TO KEEP THE COST OF YOUR CARE AS LOW AS POSSIBLE. WE ARE COMMITTED TO YOUR TREATMENT BEING SUCCESSFUL. PLEASE UNDERSTAND THAT PAYMENT OF YOUR BILL IS CONSIDERED PART OF YOUR TREATMENT. REGARDLESS OF ANY INSURANCE STATUS, YOU ARE RESPONSIBLE FOR THE BALANCE DUE ON YOUR ACCOUNT. YOU ARE RESPONSIBLE FOR ANY AND ALL PROFESSIONAL SERVICES RENDERED. AS A COURTESY TO YOU, OUR OFFICE PROVIDES CERTAIN SERVICES, INCLUDING PRE-TREATMENT ESTIMATES WHICH WE SEND TO THE INSURANCE COMPANY AT YOUR REQUEST. IT IS IMPOSSIBLE FOR US TO KNOW EVERY ASPECT OF YOUR INSURANCE, BUT WE WILL COORDINATE WITH THEM TO PROVIDE THE MOST ACCURATE ESTIMATES.

PLEASE BE AWARE SOME OR PERHAPS ALL OF THE SERVICES RENDERED MAY OR MAY NOT BE COVERED BY YOUR INSURANCE POLICY. IT IS UP TO YOU TO CONTACT YOUR INSURANCE COMPANY AND INQUIRE AS TO WHAT BENEFITS YOU HAVE. IF YOU HAVE ANY QUESTIONS CONCERNING THE PRE-TREATMENT ESTIMATE AND/OR FEE FOR SERVICE, IT IS YOUR RESPONSIBILITY TO HAVE THESE QUESTIONS ANSWERED PRIOR TO TREATMENT TO MINIMIZE ANY CONFUSION. FULL PAYMENT IS DUE AT THE TIME OF SERVICE. IF INSURANCE BENEFITS APPLY, ESTIMATED PATIENT CO-PAYMENTS, DEDUCTIBLES, AND CO-INSURANCES ARE DUE AT THE TIME OF SERVICE. ANY BALANCE ON YOUR ACCOUNT IS YOUR RESPONSIBILITY TO PAY, WHETHER OR NOT YOUR INSURANCE COMPANY PAYS ANY PORTION.

WE MAKE EVERY EFFORT TO RETURN A CREDIT BALANCE ON YOUR ACCOUNT IN A TIMELY MANNER. ONCE YOUR TREATMENT IS COMPLETE AND THE ACCOUNT IS CLOSED, WE WILL ISSUE REFUNDS BETWEEN 60 – 90 DAYS. PLEASE SPEAK TO OUR BILLING OFFICE FOR QUESTIONS OR CONCERNS.

THE SIGNATURE ON FILE IS MY AUTHORIZATION FOR THE RELEASE OF FINANCIAL INFORMATION NECESSARY TO PROCESS MY CLAIM. I HEREBY AUTHORIZE PAYMENT TO WOOD & MYERS, AND/OR MY DOCTOR RENDERING SERVICE AND/OR TREATMENT.

Signature of Patient, Parent, Guardian (2)

INSURANCE POLICY

IF YOU HAVE INSURANCE, WE CAN ASSIST YOU IN SUBMITTING YOUR CLAIM. YOUR INSURANCE CLAIM WILL ONLY BE COMPLETED AND SUBMITTED IF WE ARE PROVIDED WITH ALL PERTINENT INSURANCE COMPANY INFORMATION. IT IS YOUR RESPONSIBILITY TO VERIFY THAT YOUR POLICY IS IN EFFECT AT THE TIME YOUR SERVICES ARE RENDERED. YOU ARE RESPONSIBLE FOR PAYMENT AT THE TIME OF SERVICE. WE MAY NOT BE AWARE OF YOUR SPECIFIC INSURANCE PLAN LIMITATIONS WHICH MAY RESULT IN A PAYMENT THAT DIFFERS FROM OUR ESTIMATED OR ACTUAL COST OF TREATMENT SUCH AS:

MISSING TOOTH CLAUSE
PROCEDURES WHICH ARE NOT A BENEFIT
INACCURATE INFORMATION RECEIVED FROM THE PATIENT
ANNUAL BENEFIT MAXIMUM BEING REACHED
CHANGES OR TERMINATION OF COVERAGE

FEES RESULTING FROM LIMITS AND EXCLUSIONS ARE THE PATIENT’S RESPONSIBILITY. INSURANCE IS AN AGREEMENT BETWEEN YOU AND YOUR INSURANCE COMPANY. WE WILL INFORM YOU IF WE ARE PARTICIPATING WITH YOUR INSURANCE PLAN AND WILL HANDLE YOUR CLAIM ACCORDING TO OUR AGREEMENT WITH THE INSURANCE COMPANY. WE FILE INSURANCE CLAIMS AS A COURTESY TO YOU, OUR PATIENT. WE WILL NOT BECOME INVOLVED IN DISPUTES BETWEEN YOU AND YOUR INSURANCE COMPANY REGARDING DEDUCTIBLES, CO-PAYMENTS, COVERED AND NON-COVERED CHARGES, SECONDARY INSURANCES, “USUAL AND CUSTOMARY” CHARGES, ETC., OTHER THAN TO SUPPLY NECESSARY FACTUAL INFORMATION. DEDUCTIBLES AND/OR CO-PAYMENTS ARE REQUIRED TO BE PAID BY YOU AT THE TIME OF SERVICE. YOU ARE RESPONSIBLE FOR THE PAYMENT OF YOUR ACCOUNT. IF PAYMENT IS NOT RECEIVED FROM YOUR INSURANCE COMPANY, THE BALANCE OF THE ACCOUNT BECOMES YOUR RESPONSIBILITY. I HEREBY AUTHORIZE AND AGREE AS FOLLOWS:

I AUTHORIZE THE USE OF THIS FORM ON ALL MY INSURANCE SUBMISSIONS.
I AUTHORIZE RELEASE OF INFORMATION TO ALL MY INSURANCE COMPANIES.
I UNDERSTAND I AM RESPONSIBLE FOR MY ACCOUNT.
I AUTHORIZE WOOD & MYERS TO ACT AS MY AGENT TO OBTAIN APPROVAL FROM MY INSURANCE COMPANIES.
I AUTHORIZE PAYMENT DIRECTLY TO WOOD & MYERS AND/OR MY DOCTOR.
I PERMIT A COPY OF THIS AUTHORIZATION TO BE USED IN PLACE OF THE ORIGINAL.
I UNDERSTAND BENEFIT INFORMATION GIVEN TO ME BY WOOD & MYERS IS NOT A GUARANTEE OF REFUND.
I UNDERSTAND THAT MY ACCOUNT BALANCE MUST BE PAID REGARDLESS OF MY INSURANCE.

I HAVE READ THE ABOVE FINANCIAL POLICY AND UNDERSTAND THAT I AM FINANCIALLY RESPONSIBLE FOR ALL CHARGES, WHETHER OR NOT THEY ARE PAID BY MY INSURANCE. I UNDERSTAND THAT IF MY ACCOUNT IS NOT PAID WITHIN 90 DAYS, IT WILL BE TURNED OVER TO THE CREDIT BUREAU FOR COLLECTION AND A 30% COLLECTION FEE WILL BE ADDED.

Signature of Patient, Parent, Guardian (3)

ATTENTION MEDICARE RECIPIENTS:

MEDICARE WILL ONLY PAY FOR SERVICES THAT THEY DETERMINE TO BE REASONABLE AND NECESSARY UNDER SECTION 1862(A)(1) OF THE MEDICARE LAW. IF MEDICARE DETERMINES THAT A PARTICULAR SERVICE, ALTHOUGH IT WOULD OTHERWISE BE COVERED, IS "NOT REASONABLE AND NECESSARY" UNDER MEDICARE PROGRAM STANDARDS, MEDICARE WILL DENY PAYMENT FOR THAT SERVICE.

IF MEDICARE DENIES PAYMENT, I AGREE TO BE PERSONALLY AND FULLY RESPONSIBLE FOR PAYMENT.

Signature of Patient, Parent, Guardian

CONSENT FOR USE AND DISCLOSURE OF HEALTH INFORMATION

SECTION A: PATIENT GIVING CONSENT

Patient Name

SOC SEC #

SECTION B: TO THE PATIENT—PLEASE READ THE FOLLOWING STATEMENTS CAREFULLY

Purpose of Consent: BY SIGNING THIS FORM, YOU WILL CONSENT TO OUR USE AND DISCLOSURE OF YOUR PROTECTED HEALTH INFORMATION TO CARRY OUT TREATMENT, PAYMENT ACTIVITIES, AND HEALTHCARE OPERATIONS.

Notice of Privacy Practices: YOU HAVE THE RIGHT TO READ OUR NOTICE OF PRIVACY PRACTICES BEFORE YOU DECIDE WHETHER TO SIGN THIS CONSENT. OUR NOTICE PROVIDES A DESCRIPTION OF OUR TREATMENT, PAYMENT ACTIVITIES, AND HEALTHCARE OPERATIONS, OF THE USES AND DISCLOSURES WE MAY MAKE OF YOUR PROTECTED HEALTH INFORMATION, AND OF OTHER IMPORTANT MATTERS ABOUT YOUR PROTECTED HEALTH INFORMATION. A COPY OF OUR NOTICE ACCOMPANIES THIS CONSENT. WE ENCOURAGE YOU TO READ IT CAREFULLY AND COMPLETELY BEFORE SIGNING THIS CONSENT. WE RESERVE THE RIGHT TO CHANGE OUR PRIVACY PRACTICES AS DESCRIBED IN OUR NOTICE OF PRIVACY PRACTICES. IF WE CHANGE OUR PRIVACY PRACTICES, WE WILL ISSUE A REVISED NOTICE OF PRIVACY PRACTICES, WHICH WILL CONTAIN THE CHANGES. THOSE CHANGES MAY APPLY TO ANY OF YOUR PROTECTED HEALTH INFORMATION THAT WE MAINTAIN.

YOU MAY OBTAIN A COPY OF OUR NOTICE OF PRIVACY PRACTICES, INCLUDING ANY REVISIONS OF OUR NOTICE, AT ANY TIME BY CONTACTING:

WOOD & MYERS ORAL AND MAXILLOFACIAL SURGERY, P.C.
ATTN: SITE MANAGER/PRIVACY OFFICER
207 SOUTH 32ND STREET, CAMP HILL, PA 17011
(717) 763-1970 PHONE or (717) 975-2891 FAX

Right to Revoke: YOU WILL HAVE THE RIGHT TO REVOKE THIS CONSENT AT ANY TIME BY GIVING US WRITTEN NOTICE OF YOUR REVOCATION SUBMITTED TO THE CONTACT PERSON LISTED ABOVE. PLEASE UNDERSTAND THAT REVOCATION OF THIS CONSENT WILL NOT AFFECT ANY ACTION WE TOOK IN RELIANCE ON THIS CONSENT BEFORE WE RECEIVED YOUR REVOCATION, AND THAT WE MAY DECLINE TO TREAT YOU OR TO CONTINUE TREATING YOU IF YOU REVOKE THIS CONSENT.

I HAVE HAD FULL OPPORTUNITY TO READ AND CONSIDER THE CONTENTS OF THIS CONSENT FORM AND YOUR NOTICE OF PRIVACY PRACTICES. I UNDERSTAND THAT, BY SIGNING THIS CONSENT FORM, I AM GIVING MY CONSENT TO YOUR USE AND DISCLOSURE OF MY PROTECTED HEALTH INFORMATION TO CARRY OUT TREATMENT, PAYMENT ACTIVITIES AND HEATH CARE OPERATIONS.

Signature of Patient, Parent, Guardian (4)

EXAM & TREATMENT PLAN AUTHORIZATION

WHEN NECESSARY, I AUTHORIZE THE DOCTOR AND WOOD & MYERS STAFF TO PERFORM AN ORAL AND MAXILLOFACIAL EXAMINATION FOR THE PURPOSE OF DIAGNOSIS AND TREATMENT PLANNING. I ALSO AUTHORIZE THE TAKING OF ANY X-RAYS DEEMED NECESSARY AS WELL AS CLINICAL PICTURES INCLUDING INTRAORAL AND EXTRAORAL FACIAL PHOTOGRAPHS. I AUTHORIZE THAT ANY INFORMATION ACQUIRED IN THE COURSE OF MY TREATMENT MAY NEED TO BE RELEASED TO MY OTHER DOCTORS AND/OR INSURANCE COMPANIES. ADDITIONALLY, I PERMIT MY CONTACT INFORMATION SUCH AS CELL PHONE, HOME PHONE AND EMAIL TO BE USED IN THE COURSE OF TREATMENT FOR APPLICABLE COMMUNICATION. FURTHERMORE, I HEREBY ACKNOWLEDGE THAT THE OFFICE’S NOTICE OF PRIVACY PRACTICES WILL BE MADE AVAILABLE TO ME UPON REQUEST AND IF I HAVE ANY QUESTIONS, I WILL ADDRESS THEM AT MY APPOINTMENT.

Signature of Patient, Parent, Guardian (5)