Patient Information

Thank you for choosing our practice for your oral surgery needs. If you have questions or concerns about content or any other information in this form, do not hesitate to ask for assistance. We will be happy to help. Thanks for your cooperation.

Patient's Name

Birth Date

Age

Marital Status

Sex

Street Address

City

State

Zip Code

Cell Phone

Home Phone

What's the reason for your visit today?

General Dentist Name

Orthodontist's Name

Preferred Pharmacy (Name, Address & Phone)

Have any of your family members been patients at this office? Names

Names of family members at this office

RESPONSIBLE PARTY

Name of person responsible for Account

Social Security No.

Relationship to Patient

Street Address

City

Same as above

State

Zip Code

Phone

Employer

Work Phone

IN CASE OF EMERGENCY

Emergency Contact Name

Relationship to Patient

Phone No.

Relationship to Patient

Name

HOW DID YOU HEAR ABOUT US?

Referred by my doctor

Other

Name

Medical History

PLEASE ANSWER ALL QUESTIONS BY CIRCLING YES (Y) OR NO (N). ALL RESPONSES ARE KEPT CONFIDENTIAL.

ANY ADVERSE EFFECTS FROM DENTAL TREATMENT? Yes No

DO YOU HAVE JAW POPPING OR PAIN? Yes No

FAMILY HISTORY OF SEVERE REACTION TO GENERAL ANESTHESIA Yes No

List all Operations and Hospital

5. DO YOU HAVE OR HAVE YOU HAD:

SINUS OR NASAL PROBLEMS OR ALLERGIES Yes No

SLEEP APNEA Yes No

STROKE, SEIZURE, EPILEPSY Yes No

MENTAL HANDICAP, PSYCHIATRIC TREATMENT Yes No

ALZHEIMER'S OR PARKINSON'S Yes No

CONGENITAL HEART DISEASE, HEART SURGERY, CHEST PAIN, HEART ATTACK, CONGESTIVE HEART FAILURE, HEART MURMUR Yes No

LUNG DISEASE: ASTHMA, COPD Yes No

BRONCHITIS, PNEUMONIA OR TUBERCULOSIS Yes No

BLEEDING DISORDER OR TENDENCY Yes No

ANEMIA Yes No

LIVER DISEASE: JAUNDICE, HEPATITIS Yes No

KIDNEY DISEASE Yes No

DIABETES Yes No

THYROID DISEASE Yes No

REFLUX OR STOMACH ULCERS Yes No

COLITIS - ULCERATIVE OR CROHN'S Yes No

GLAUCOMA Yes No

ARTHRITIS Yes No

OSTEOPOROSIS Yes No

CANCER Yes No

RADIATION (X-RAY) TREATMENT FOR CANCER Yes No

IMPLANTS PLACED ANYWHERE IN YOUR BODY Yes No

ANY DISEASE THAT HAS DEPRESSED YOUR Yes No

U. Any other disease or disorder not listed above, please list

6. ARE YOU USING OR TAKING ANY OF THE FOLLOWING:

Antibiotics Yes No

ANTICOAGULANTS (BLOOD THINNERS) Yes No

HIGH BLOOD PRESSURE OR HEART MEDICINE Yes No

STEROIDS (CORTISONE) Yes No

MEDICATIONS FOR DIABETES (ORAL OR INJECTABLE) Yes No

WEIGHT LOSS DRUGS (OZEMPIC, MOUNJARO, WEGOVY, TRULICITY, ETC.) Yes No

DRUGS FOR BONES - OSTEOPOROSIS or CANCER(currently using or used in past) Fosamax, Boniva, Prolia, Zometa, Avastin, Nexavar, Sutent etc. Yes No

MARIJUANA OR OTHER "STREET DRUGS" Yes No

List all medications

7. ARE YOU ALLERGIC OR HAVE YOU HAD A BAD REACTION TO:

GENERAL ANESTHESIA OR LOCAL ANESTHETICS Yes No

PENICILLIN, AMOXICILLIN, CEPHAL Yes No

ASPIRIN OR IBUPROFEN Yes No

CODEINE, HYDROCODONE, OR OTHER PAIN MEDICATIONS Yes No

Latex Yes No

F. Other allergies or reactions - please list

DO YOU SMOKE, CHEW, OR DIP TOBACCO Yes No

DO YOU HAVE OR HAVE YOU HAD AN ALCOHOL Yes No

10. FOR WOMEN ONLY:

A. 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, 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 medications is completed. Please contact your physician for further assistance.

B. If you are pregnant, possibly pregnant or trying to become pregnant, anesthesia and other medications may significantly harm your developing baby, especially during the first trimester.

PLEASE ADVISE YOUR DOCTOR IF THERE IS ANY CHANCE OF YOUR BEING PREGNANT!

Are you pregnant? Yes No

Are you nursing? Yes No

I UNDERSTAND THE IMPORTANCE OF AN ACCURATE HEALTH HISTORY TO ASSIST THE DOCTOR IN PROVIDING THE BEST CARE POSSIBLE.

Signature of person completing health history

Date

Insurance Information

Patient Name

Please complete your insurance information below. If you are a self pay patient and no insurance will be processed for your visit, check the self pay option below and sign this document. Thank You!

SELF PAY (No Insurance)

DENTAL INSURANCE INFORMATION

Primary holder

Name of Primary Holder

Birthday of Primary Holder

Social Security No. of Primary Holder

Employer of Primary Holder

Insurance Company Name

Insurance Company Phone #

Subscriber ID #

Group #

MEDICAL INSURANCE INFORMATION

Primary holder #2

Name of Primary Holder #2

Birthday of Primary Holder #2

Social Security No. of Primary Holder #2

Employer of Primary Holder #2

Insurance Company Name #2

Insurance Company Phone #2

Subscriber ID #2

Group #2

PLEASE READ THIS CAREFULLY

You are entering into a relationship with the doctor, in which the doctor agrees to treat the patient and the patient agrees to pay the doctor's fee for treatment. As a courtesy we will assist you by filing your claim to your primary insurance company for all office visits. On the day of surgery you will pay your estimated portion of the total fee. Keep in mind, this amount is based on what your insurance company has told us regarding what they will pay for the surgery.

Please remember, these are only estimates and are not always accurate. If we are misquoted by your insurance company, we are not responsible for their mistake and you will be billed based on your insurance company explanation of benefits. A pre-treatment estimate can be sent by our office to your insurance company and is the most accurate estimate that can be obtained. If you would like to wait on a pre-treatment estimate, please inform our office. Once insurance has paid, you will be billed or refunded accordingly.

For the purpose of filing claims/Insurance verification, I authorize the release of any information and I assign benefits to the doctor. By signing below, I agree to the above terms of financial responsibility.

Signature of Patient or Authorized Representative

Date

Insurance Information

To ensure your benefits are verified before your arrival and to avoid delays at check-in, please upload clear images of the front and back of your current 2026 medical insurance card(s).

To make sure your files can be sent, we have a maximum total upload size of 10 MB.
Total upload size: 0 MB / 10 MB

Front

Back

Financial Policy

Patient care is always our first priority. We take pride in delivering the finest care at a reasonable cost. For that reason it is important to have a good understanding regarding our office financial policies and your responsibilities.

INSURANCE PROCESSING

Your insurance coverage is determined by your insurance plan, and it's your insurance company that decides your benefits. We are not responsible for any limitation in coverage that may be included in your plan. The financial obligation for our services rests on you.

As a courtesy to our patients we will file up to two insurance claims (dental-dental / medical-dental). If you have a secondary dental insurance that requires medical denial, only primary insurance will be filed and you will be responsible for the balance. You can then file directly with your secondary insurance. We will gladly provide you with a copy of your itemized statement.

Please understand that even if you do have more than one medical and/or dental insurances, you might still have a deductible, co-insurance and/or co-pay obligation. It is your responsibility to pay any denied or unpaid balance in full.

ATTENTION PATIENTS WITH OUT OF NETWORK INSURANCES

If our providers are NOT in-network with your insurance plan, all procedures will be processed by your insurance as out-of-network. This means you will have to pay based on out-of-network coverage % and the explanation of benefits (EOB) from your insurance company won't necessarily match your financial responsibility with our office.

Even if we are informed that you have out-of-network benefits under your insurance company, certain types of plans will not pay any money if the patient requests and seeks services from a non participant provider. It is your responsibility to confirm this information with your insurance provider.

ATTENTION MEDICARE PATIENTS

We are not MEDICARE providers, for that reason we can not file claims to supplemental medical insurance for patients covered under Medicare. If you have a separate dental coverage, and your procedure is considered dental, we will verify your insurance benefits and quote our services accordingly. If a Medicare explanation of benefits is required for any dental or medical procedures, patient will be responsible for the full balance.

PLEASE READ CAREFULLY

As a benefit to our patients, we will verify your insurance benefits prior to your appointment, you are responsible to provide your insurance information at least 2 business days prior to your appointment. Failing to do so, you will be treated as Self-Pay and your estimated out of pocket will be determined the day of your appointment.

As a courtesy to our patients, our office will file up to two insurance claims on your behalf.

If the balance is under $50 once primary insurance pays, the patient will be responsible to submit to their secondary insurance, a secondary claim will not be submitted and the patient will be responsible for the balance.

Any treatment plan's estimated co-payments or deductible amounts (patient portion) are due at time services are performed.

If your insurance is terminated prior to surgery, you will be responsible for the procedure at regular office fees.

If your insurance company misquotes your benefits to us, we are not responsible for their mistake. You will be billed for any amounts not covered according to insurance explanation of benefits.

Since your available benefits may change, treatment plan estimates are valid 30 days from the date of your consult. It's your insurance that determines your financial responsibility.

Your insurance company may refuse payment of your claim, in which case you will be responsible for the entire bill.

The best way to obtain the most accurate quote from your insurance company is to send a pre-treatment estimate or pre-determination. Insurance estimates may take 3 to 6 weeks to be processed. They are not a guarantee of coverage or payment. You may request the pre-treatment / pre-determination from our Treatment Coordinator before you leave your consult appointment.

SELF PAY PATIENTS

Your treatment plan estimate will be valid for 60 days from the day you sign your estimate.

SCHEDULING POLICY

A $100.00 surgery scheduling fee will be charged when a patient schedules surgery. This fee will be applied to patient's balance once insurance is processed. If patient does not comply with our cancellation policy, the $100.00 surgery scheduling fee will be forfeited. For surgeries that require two or more hours, a customized schedule fee will be requested at the time of scheduling.

Because your schedule may change, if your appointment is more than two months in the future, we will need to verify that you want to keep that appointment closer to surgery. We will need to confirm your appointment 7-14 days prior to surgery. We will try to contact you during this time frame. If we are unable to contact you but the original surgery date no longer works, our scheduling fee can be refunded or applied to another appointment date if given the proper 2 business day notice.

CANCELLATION POLICY

If you must cancel or reschedule your surgery, please allow at least 2 business days notice. There will be a late cancellation charge that equals your scheduling fee, if you no-show, cancel or reschedule your surgery with less that 2 business days notice. If proper notice is not given or you simply do not show up for your appointment, and you would like to re-schedule your procedure, you will be required to pay 1/2 deposit of your estimated amount for the procedure prior to being placed back on the surgery schedule.

PAYMENTS POLICY

For your convenience, we accept Visa, MasterCard, Discover, debit card (Visa or MasterCard logo), money orders and cash. If one of these are not an option for you, you can apply for Care Credit, which is a third party payment plan alternative. Personal checks will not be accepted as a method of payment. If patient pays a final balance by mailing a check, and check is returned as "insufficient funds", a fee of $35 will be added to your balance.

A patient's account remains due and payable within 30 days after the insurance processes your claim. If it becomes apparent that the patient does not intend to satisfy their unpaid balance, a collection agency may be employed to pursue collection of the account. The patient will be charged and held responsible for all collection fees incurred by Alliance Oral & Maxillofacial Surgery in collecting the debt. Those charges will be automatically added to the patient's account. Once your account is transfer to a collection agency, our office won't be able to process any payments.

I have read and understand my financial obligations as a patient / authorized representative. I acknowledge that I am fully responsible for providing correct insurance information and payment for all services not covered by my insurance company for any reason.

Signature of Patient or Authorized Representative

Date

HIPAA Authorization for Use or Disclosure

Our Notice of Privacy Practices provides information about how Alliance Oral & Maxillofacial Surgery may use and disclose your protected health information and when we need your written authorization to do so. This form complies with the HIPAA Privacy Standards and 42 CFR Part 2.

Name of Patient (print)

Date of Birth

I. My Authorization

I authorize Alliance Oral & Maxillofacial Surgery to use or disclose the following health information:

I authorize the use or disclosure of my records, including any Substance Use Disorder (SUD) records, for all current and future Treatment, Payment, and Health Care Operations (TPO) as permitted by law

All of my health information

Specific treatment or condition

Specific date range

Start Date

End Date

The above party may disclose this health information to the following recipient:

Name/Organization

Phone

Fax

II. State Law and Sensitive Information

In some cases, state or other federal laws provide greater privacy protections for specific types of "sensitive" health information. I understand that I may choose not to initial any of the categories below, and my refusal to sign will not affect my ability to receive treatment.

By initialing below, I specifically authorize the release of information related to:

Initials — Reproductive Health (Abortion/Contraception)

Initials — Infectious Disease (HIV/AIDS testing/treatment)

Initials — Mental Health (Treatment/Genetic Testing)

Initials — Substance Use Disorder (SUD Records)

III. Purpose of This Authorization

The purpose of this authorization is (check all that apply):

At my request

To authorize the using or disclosing party to communicate with me for marketing purposes when they receive payment from a third party to do so

To authorize the using or disclosing party to sell my health information

Other

Other (please specify)

V. Expiration and Revocation

This authorization remains in effect until the following date or event:

On (Date)

Expiration Date

When I am no longer a patient of the practice

Other

Other (please specify)

VI. Signatures and Acknowledgements

By signing below, I acknowledge the following:

1. Authorization: I authorize the release of all information checked in Sections I, II, and III.

2. Rights: I understand my right to revoke this in writing and the prohibition of use in legal proceedings.

3. Condition of Care: My treatment is not conditioned upon signing this authorization.

4. Notice of Privacy Practices: I have been provided with a copy of the Notice of Privacy Practices and have read and understood its content.

Signature (Self/Parent/Guardian)

Date

If signed by a Representative, state authority

Acknowledgement & Communication Permissions

Due to Health Insurance Portability and Accountability Act (HIPAA) of 1996, the following information must be filled out by each patient annually.

I authorize Alliance Oral & Maxillofacial Surgery, to release any of my medical or insurance information necessary to process my medical claims and coordinate or manage my health care.

In the event a family member or caregiver attends your office visit and is in the exam room at the time of your evaluation, I give Alliance Oral & Maxillofacial Surgery and it's physicians or employees my permission to discuss freely my condition, treatment, or diagnosis with that person.

I authorize Alliance Oral & Maxillofacial Surgery to leave a voice messages with treatment information in case I can't be reached to discuss at the moment of the call.

Patient Name

Date

Leave message #1 Yes No

HOME PHONE

WORK PHONE

Leave message #2 Yes No

CELL PHONE

Leave message #3 Yes No

May we call your name out loud in our lobby?

Name

Relationship

Name #2

Relationship #2

Name #3

Relationship #3

Patient or Authorized Representative Signature

Printed Name

Print Name

Patient or Authorized Representative Signature

Notice of Privacy Practices

Accessed on 01/27/2026

Your Information. Your Rights. Our Responsibilities.

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.

Your Rights

When it comes to your health information, you have certain rights. This section explains your rights and some of our responsibilities to help you.

Get an electronic or paper copy of your medical record

• You can ask to see or get an electronic or paper copy of your medical record and other health information we have about you. Ask us how to do this.

• We will provide a copy or a summary of your health information. We may charge a reasonable, cost-based fee.

Ask us to correct your medical record

• You can ask us to correct health information about you that you think is incorrect or incomplete. Ask us how to do this.

• We may say "no" to your request, but we'll tell you why in writing within 60 days.

Request confidential communications

• You can ask us to contact you in a specific way (for example, home or office phone) or to send mail to a different address.

• We will say "yes" to all reasonable requests.

Ask us to limit what we use or share

• You can ask us not to use or share certain health information for treatment, payment, or our operations. We are not required to agree to your request, and we may say "no" if it would affect your care.

• If you pay for a service or health care item out-of-pocket in full, you can ask us not to share that information for the purpose of payment or our operations with your health insurer. We will say "yes" unless a law requires us to share that information.

Get a list of those with whom we've shared information

• You can ask for a list (accounting) of the times we've shared your health information for six years prior to the date you ask, who we shared it with, and why.

• We will include all the disclosures except for those about treatment, payment, and health care operations, and certain other disclosures (such as any you asked us to make). We'll provide one accounting a year for free but will charge a reasonable, cost-based fee if you ask for another one within 12 months.

Get a copy of this privacy notice

• You can ask for a paper copy of this notice at any time, even if you have agreed to receive the notice electronically. We will provide you with a paper copy promptly.

Choose someone to act for you

• If you have given someone medical power of attorney or if someone is your legal guardian, that person can exercise your rights and make choices about your health information.

• We will make sure the person has this authority and can act for you before we take any action.

File a complaint if you feel your rights are violated

• You can complain if you feel we have violated your rights by contacting us at 817-741-2200.

• You can file a complaint with the U.S. Department of Health and Human Services Office for Civil Rights by sending a letter to 200 Independence Avenue, S.W., Washington, D.C. 20201, calling 1-877-696-6775, or visiting www.hhs.gov/ocr/privacy/hipaa/complaints.

• We will not retaliate against you for filing a complaint.

Your Choices

For certain health information, you can tell us your choices about what we share. If you have a clear preference for how we share your information in the situations described below, talk to us. Tell us what you want us to do, and we will follow your instructions.

In these cases, you have both the right and choice to tell us to:

• Share information with your family, close friends, or others involved in your care

• Share information in a disaster relief situation

• Include your information in a hospital directory

If you are not able to tell us your preference, for example if you are unconscious, we may go ahead and share your information if we believe it is in your best interest. We may also share your information when needed to lessen a serious and imminent threat to health or safety.

In these cases we never share your information unless you give us written permission:

• Marketing purposes

• Sale of your information

• Most sharing of psychotherapy notes

In the case of fundraising:

• We may contact you for fundraising efforts, but you can tell us not to contact you again.

• If we intend to use or disclose your substance use disorder records (subject to 42 CFR Part 2) for fundraising purposes, you have the right to elect not to receive such communications before we send them.

Our Uses and Disclosures

How do we typically use or share your health information?

We typically use or share your health information in the following ways:

Treat you — We can use your health information and share it with other professionals who are treating you.

Example: A doctor treating you for an injury asks another doctor about your overall health condition.

Run our organization — We can use and share your health information to run our practice, improve your care, and contact you when necessary.

Example: We use health information about you to manage your treatment and services.

Bill for your services — We can use and share your health information to bill and get payment from health plans or other entities.

Example: We give information about you to your health insurance plan so it will pay for your services.

How else can we use or share your health information?

We are allowed or required to share your information in other ways — usually in ways that contribute to the public good, such as public health and research. We have to meet many conditions in the law before we can share your information for these purposes. For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/index.html

Substance use disorder records (42 CFR Part 2)

• Use and disclosure: We may use and disclose your substance use disorder records subject to 42 CFR Part 2 for treatment, payment, and health care operations as permitted by law.

• Prohibition on use in legal proceedings: We are prohibited from using or disclosing your substance use disorder records subject to 42 CFR Part 2 in any civil, criminal, administrative, or legislative proceedings against you without your specific written consent or a court order.

Help with public health and safety issues

We can share health information about you for certain situations such as:

• Preventing disease

• Helping with product recalls

• Reporting adverse reactions to medications

• Reporting suspected abuse, neglect, or domestic violence

• Preventing or reducing a serious threat to anyone's health or safety

Do research

We can use or share your information for health research.

Comply with the law

We will share information about you if state or federal laws require it, including with the Department of Health and Human Services if it wants to see that we're complying with federal privacy law.

Respond to organ and tissue donation requests

We can share health information about you with organ procurement organizations.

Work with a medical examiner or funeral director

We can share health information with a coroner, medical examiner, or funeral director when an individual dies.

Address workers' compensation, law enforcement, and other government requests

We can use or share health information about you:

• For workers' compensation claims

• For law enforcement purposes or with a law enforcement official

• With health oversight agencies for activities authorized by law

• For special government functions such as military, national security, and presidential protective services

Respond to lawsuits and legal actions

We can share health information about you in response to a court or administrative order, or in response to a subpoena.

Our Responsibilities

• We are required by law to maintain the privacy and security of your protected health information.

• We will let you know promptly if a breach occurs that may have compromised the privacy or security of your information.

• We must follow the duties and privacy practices described in this notice and give you a copy of it.

• We will not use or share your information other than as described here unless you tell us we can in writing. If you tell us we can, you may change your mind at any time. Let us know in writing if you change your mind.

For more information see: www.hhs.gov/ocr/privacy/hipaa/understanding/consumers/noticepp.html

Changes to the terms of this notice

We can change the terms of this notice, and the changes will apply to all information we have about you. The new notice will be available upon request, in our office, and on our website.

E-Signature

Please sign electronically below.

Submit Signature Clear Signature

Click submit and you hereby give consent to sign this document electronically.

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